The right granted to a doctor to admit patients to a particular hospital.
Any activity done to help a person or group to get something the person or group needs or wants.
Licensed salespersons who represent one or more health insurance companies and presents their products to consumers.
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.
Licensed insurance salesperson who obtains quotes and plan from multiple sources information for clients.
The insurance company offering a health plan.
Certificate of Insurance
The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what it covered, what is not, and dollar limits.
A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.
Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For more information, visit the Department of Labor.
Coinsurance refers to money that an individual is required to pay for services, after a deductible has been paid. Coinsurance is often specified by a percentage. For example, the individual pays 20% toward the charges for a service and the carrier pays 80%.
Copayment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some carriers require a $10 "copayment" for each office visit, regardless of the type or level of services provided during the visit. Copayments are not usually specified by percentages.
Credit for Prior Coverage
This is something that may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer's (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines.
The amount an individual must pay for health care expenses before insurance covers the costs. Often, insurance plans are based on yearly deductible amounts.
Denial Of Claim
Refusal by an insurance company to honor a request by an individual to pay for health care services obtained from a health care professional.
Spouse and/or unmarried children (whether natural, adopted or step) of an insured.
The date your insurance plan begins. You are not covered until the policies effective date.
Medical services that are not covered by an insurance policy.
Explanation of Benefits
The insurance company's written explanation of a claim, showing what they paid and what the individual must pay. Sometimes accompanied by a benefits check.
A "twin" to a "brand name drug" once the brand name company's patent has run out and other drug companies are allowed to sell a duplicate of the original. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics.
Coverage through an employer or other entity that covers all individuals in the group.
Health Care Decision Counseling
Services, sometimes provided by insurance companies or employers, that help individuals weigh the benefits, risks and costs of medical tests and treatments. Unlike case management, health care decision counseling is non-judgmental. The goal of health care decision counseling is to help individuals make more informed choices about their health and medical care needs, and to help them make decisions that are right for the individual's unique set of circumstances.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations represent "pre-paid" or "capitated" insurance plans in which individuals pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided. Services are provided by physicians who are employed by, or under contract with, the HMO.
A Federal law passed in 1996 (full name is "The Health Insurance Portability and Accountability Act of 1996.") that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care.
Providers or health care facilities which are part of a health plan's network of providers with which it has negotiated rates for their services. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
Indemnity Health Plan
Indemnity health insurance plans are also called "fee-for-service." These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the limitation exists in the amount of the reimbursement that an insured party can receive to cover medical expenses. The medical expense reimbursement amount can range from a per day cost and set percentage to the actual costs of the medical expenses. Indemnity health plans offer individuals the freedom to choose their health care professionals.
Individual Health Insurance
Health insurance coverage on an individual, not group, basis. The premium is usually lower for an individual health insurance plan than for a group policy.
Lifetime Maximum Benefit (or Maximum Lifetime Benefit)
the maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
Long-Term Care Policy
Insurance policies that cover specific services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include nursing care, home health care services, and custodial care.
Long-term Disability Insurance
Pays an insured a percentage of their monthly earnings if they become disabled.
LOS refers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality, by emphasizing prevention of disease.
Maximum Dollar Limit
The maximum amount of money that an insurance company will pay for claims within a specific time period.
Medigap Insurance Policies
Medigap insurance is offered by private insurance companies, not the government. It is not the same as Medicare or Medicaid. These policies are designed to pay for some of the costs that Medicare does not cover.
A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan. Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual's insurance company.
A predetermined limited amount of money that an individual must pay out of their own pocket, before an insurance company will pay 100 percent for an individual's health care expenses.
An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.
A medical condition which existed prior to the individual obtaining a policy from the particular insurance company.
Preferred Provider Organizations (PPOs)
You receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care.
Primary Care Provider (PCP)
A health care professional (usually a physician) who is responsible for monitoring an individual's overall health care needs.
Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.
Reasonable and Customary Fees
The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure.
A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).
The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications' side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice.
It is a medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to obtain second opinions whenever a physician recommends surgery or presents an individual with a serious medical diagnosis.
Short Term Medical
Temporary coverage for an individual for a short period of time, usually from 30 days to 11 months.
An injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual's full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.
State Mandated Benefits
When a state passes laws requiring that health insurance plans include specific benefits.
The dollar amount of claims filed for eligible expenses at which point you've paid 100% of your out-of-pocket and the insurance begins to pay at 100%. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of coinsurance.
The company that assumes responsibility for the risk, issues insurance policies and receives premiums.
Usual, Customary and Reasonable (UCR) or Covered Expenses
An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
A period of time when you are not covered by insurance for a particular problem.