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Health Insurance Glossary

Additional Insured: Anyone covered under your health plan that is not named as “insured” in your documentation from the insurance company.

Appeals Process: This process lets you ask for a review of claims that have been denied by your health

Ancillary Services: These are services provided to support your health care. Some examples include x-rays or lab tests.

Benefit: This refers to medical services covered by your health plan. This word is also used to describe your health plan in general. It can also mean payment received under a plan.

Benefit Period: The interval during which you will be eligible for benefits. Generally, your benefit period will begin with the first medical service you received for a specific illness and end after you have not been treated for that condition for 60 days.

Carrier: The insurance company you receive your health plan from.

Certificate of Insurance: This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier. It spells out precisely what will be covered, what won’t, and the dollar maximums.

Claim: This refers to any request to your insurance company for benefits.

COBRA: This acronym refers to the Consolidated Omnibus Budget Reconciliation Act of 1985. The law requires group medical plans covering twenty employees or more to offer participants the option to receive continued healthcare benefits for up to eighteen months after the cancellation of their group plan.

Coinsurance: The amount you will be required to pay for a particular medical expense. Coinsurance is measured as a percentage of the total medical bill.

Co-payment: This is a cost-sharing arrangement in which you will be responsible for a specific charge for a specific medical service ($20.00 per office visit, or $10.00 per generic prescription).

Covered Expenses: The various medical procedures that your insurer has agreed to provide you coverage for.

Deductible: The amount you’ll be required to pay for healthcare expenses before your insurance plan will begin to reimburse you.

Dependent: This is a person who is covered under the subscribers plan. It can be a child, spouse or domestic partner.

Domestic Partners: This means two people who live together but are not married. They are responsible for each other’s well-being and finances. They may or may not be a same-sex couple

Exclusion: These are conditions or services that the health plan does not cover.

Effective Date: This refers to the date on which your insurance coverage will actually begin to cover you.

Eligibility: This includes terms that decide who can get coverage. The requirements vary. They could include health conditions, how long a person is employed, job status and more.

Emergency: This is a serious illness or injury. It comes on suddenly. It is something that needs immediate medical care. If a person does not get care quickly, death or serious health problems may occur.

Explanation of Benefits (EOB) This is a statement a health plan sends to a health plan member. It shows charges, payments and any balances owed. It may be sent by mail or email

Fee-for-Service: This is a payment system for healthcare where your provider is paid for each service after it is performed. You receive reimbursement after you file a claim.

Health Reimbursement Arrangement (HRA): This is a part of a health plan that lets members use a fund to pay health care costs. The member’s employer puts money into a fund. Members can use the fund to pay deductibles, co-insurance and other covered health care costs. Unused money can usually be rolled over and used in the next plan year

High-deductible Health Plan (HDHP): This health plan has to meet federal rules. This is so members can put money into a health savings account or health reimbursement arrangement. These funds can help pay for health care. The plan deductible is higher than a standard health plan. Premiums are lower

HMO: Health Maintenance Organization. HMO’s are popular health benefit programs in which you’ll pay monthly premiums in return for managed coverage for your checkups, hospital stays, doctors' visits, surgery, emergency care, preventive care, lab tests, and X-rays. If you join an HMO, you will have to select what’s called a “Primary Care Physician” who will be responsible for coordinating your healthcare and making any referrals to specialists that you require. You’ll also have to use doctors, hospitals and clinics who are members of your HMO plan's network.

Home Health Care: Home health care means health care services given in a patient’s home. It is often offered after a hospital stay. Coverage depends on the patient’s needs and his or her health plan.

Independent Practice Association (IPA): This is a group of doctors or other health care providers. They contract with one or more health plans to provide services. If a member sees a primary doctor in this group, he or she will be referred to specialists and hospitals in the same group. Members can go outside the group if their medical needs cannot be handled by this group

Inpatient Care: This is care given to a person who has been admitted to the hospital. This person will stay one or more nights

In-network: This refers to health care Facilities or Providers, who are part of the health plan's network. It means they contract with the plan to deliver services at a set rate.

Lapse (or Lapse in Coverage): Anyone who buys an insurance plan pays a premium you pay this amount every month. If you miss a payment, the insurance company can cancel your coverage. It means you have let your insurance coverage lapse. You have let it end.

Lifetime Limit: This refers to the cap (or maximum level) on benefits available through a policy.

LOS: This is an acronym for the term “length of stay”. It’s used by insurance carriers, case managers, and other healthcare professionals to describe the length of time any individual spends in a hospital or an in-patient care facility.

Mail-order Pharmacy: People can get prescription drugs through the mail using this. It is a service that health plans often offer. Members can save time and money using it by getting a three-month supply all at once

Maximum Out-of-Pocket Expenses: The most you will have to pay during one year — in the form of deductibles and coinsurance fees.

Managed Care: This term refers to an increasingly broad assortment of health plans that manage healthcare costs and usage. There are three major types of managed health plans: HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and POS (Point-Of-Service plans).

Medicaid: This is a joint state/federal health insurance program that is administered by the state. It provides health coverage for low-income individuals, especially pregnant women, children and the disabled.

Medicare: This is a federally-sponsored healthcare program that offers coverage for medical and hospital care primarily to those over the age of 65.

Member: A member is someone who belongs to a health plan. Sometimes, a member is known as an “enrollee.” The term “Member” shall mean a Subscriber and/or a Dependent.

Member Services: This is a department in a health plan company. It helps people understand how their health plan works. It can, answer questions on the phone, mail out plan documents replace member ID cards. People usually find the phone number for Member Services on their ID card.

Network: This refers to the groups of doctors, hospitals and other medical professionals who have been contracted to provide discounted healthcare services to your insurance carrier’s customers.

Negotiated Charge: This is the maximum charge a Preferred Care Provider has agreed to make as to any service or supply for the purpose of the benefits under this Plan.

Out-of-Network: This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO, POS, or PPO). Depending on your plan’s guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.

Out-of-Pocket Costs: These are medical costs that a member must pay. Co-pays and deductibles are examples.

Out-of-Pocket Maximum: This is a limit on the costs a health plan member must pay for covered services. The limit can be yearly or a dollar amount.

Outpatient Care: This is care a person gets in a clinic, emergency room, hospital or surgery center. The person gets the care and goes home. There is no overnight stay.

Outpatient Procedure: Some procedures can be done in a hospital, surgery center or doctor’s office. The person gets it done and goes home. There is no overnight stay. This is also called “ambulatory surgery.”

Participating Provider: This is a doctor, hospital or other health care provider. The provider signs a contract with a health plan. The provider is part of the plan’s network for covered services. People may pay less when they visit this type of provider

Policyholder: This is a person who has a contract with an insurance company.

Portability: This is a legal right of an insured person. The person gets to keep group insurance. The person keeps it as an individual policy. The person does not need to prove he or she is in good health to keep the policy.

POS: Point-of-Service Plan. A POS is a managed healthcare plan that combines the features of a Health Maintenance Organization and a Preferred Provider Organization. These plans allow you to decide whether or not you’ll use an in-network provider or an out-of-network provider.

Preferred Participating Hospital: Hospital that has entered into an Agreement with an Insurance Carrier.

Preferred Provider Organization (PPO): Are networks of healthcare providers who have negotiated discount contracts with health insurance carriers. Members can choose any doctor, they do not have to name a primary care physician, and no referrals are needed. Members who go to network providers usually get more coverage and may pay less for services.

Premium Waiver: This is a phrase in a contract. It means an insurer can keep up life insurance coverage for a disabled employee. The employee does not pay for the coverage.

PPO: Preferred Provider Organization. PPOs are networks of healthcare providers who have negotiated discount contracts with health insurance carriers. Your healthcare provider decisions will be up to you, but there are generally financial incentives for you to select providers within your PPO network.

Pre-existing Conditions: This refers to any healthcare issues you had prior to your insurance plan’s effective date. Many policies will refuse to cover pre-existing conditions, while others do so only for a short time.

Preventative Care: This type of care is often covered in a health plan. It includes programs or services that can help people prevent disease. It may include yearly exams, immunization, diagnostic tests for some diseases. The tests are sometimes called screenings.

Prior creditable coverage: This term means type of health coverage a person has had. People sometimes need to prove they have had this so they can be fully covered by a new plan, example of an acceptable type is, group or individual coverage.

Premium: The dollar amount you’ll pay on a monthly basis in exchange for your insurance coverage.

Primary Care Physician: Most HMOs and POS plans will require you to select one family physician, pediatrician or internist to monitor your health, treat most of your health problems, and refer you to specialists when necessary.

Provider: This term refers to any individual (nurse, physician, or specialist) or institution (clinic, hospital, or laboratory) that provides you with care.

Qualifying Event: This is an event that lets a member change his or her health benefits. Examples include death, job loss, divorce and marriage.

Referral: This is a form your doctor gives you so you can get care from a specialist or health care facility. It may be written or sent by computer

Renewal: This is when an insurance policy continues, but with changed terms, like new rates.

Rider: This refers to any policy attachment that makes additions or changes to your original insurance plan.

Short Term Health Insurance: This type of healthcare plan is purchased to provide you with benefits during coverage gaps between jobs, after a move, or while you’re traveling overseas.

Small Business Health Insurance: This is a type of healthcare coverage that is available to businesses employing between two and fifty employees. It offers discounted premiums to employees and tax advantages to small business owners; also in most cases, the coverage cannot be denied.

Subscriber: This is a person who signs up for a health plan. If the plan is a family health plan, the person can add members in the family known as your (dependents).Those people must be eligible to be added. Some health plans also use the word “enrollee” for this term.

Summary of Benefits and Coverage "SBC": A uniform four-page, double-sided document that describes the benefits and coverage under a plan, including cost-sharing requirements and any information regarding exceptions, reductions, or limitations. Under the Affordable Care Act (ACA), active health plans will be required to provide consumers with a concise SBC document detailing, in plain language and a consistent format, information about health plan benefits and coverage.

Travel Health Insurance: This insurance is purchased to provide you with coverage when you’re traveling abroad.

Underwriting: This process helps assess the costs of insuring potential members. It is used to decide who is eligible for coverage. Medical questions may be asked. A health exam may be required. Rate level and premiums are based on results

Urgent Care: Urgent care is not the same as emergency care. It is for a sudden illness or injury that is not life threatening. But care still needs to be given quickly so the person does not develop more serious pain or problems

Voluntary Plans: These are group benefits offered by the employer. They are paid for completely by the employees

Waiting Period: This refers to a pre-specified time period during which you will not be covered by your insurance (for a particular healthcare issue).

Well Baby Care: This is the routine care a child needs through the age of eight. It includes checkups, tests and shots.

Well Woman Care: This is the regular care a woman needs. It includes checkups with the Ob/Gyn and regular pregnancy care.

Workers' Compensation: This covers workers when they are hurt on the job. These workers receive pay for medical costs and disability pay under this law. It is available in all 50 states, American Samoa, Guam, Puerto Rico and the U.S. Virgin Islands.

X-ray: This is a picture that can show bones and other internal parts of the body. It is used to help diagnose certain conditions

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