A
accidental
death and dismemberment (AD&D) rider
A supplement to many life insurance policies that provides
an additional cash benefit to the insured or his/her
beneficiaries if an accident causes either the death
of the insured or causes the insured to lose any two
limbs or the sight in both eyes.
annual
out-of-pocket maximum
A dollar amount set by the plan which puts a cap on
the amount of money the insured must pay out of his
or her own pocket for covered expenses over the course
of a calendar year.
applicant
The person or business that applies for an insurance
policy.
B
beneficiary
The person or party the owner a life insurance policy
names to receive the policy benefit in the event of
the insured's death.
brand-name
(medications)
Prescription medications that are manufactured by the
developer of the medication in question.
broker
A commissioned sales agent who is under contract to
and sells the insurance products of more than one insurance
company.
C
calendar-year
deductible
An amount that the insured person must pay before insurance
payments for covered services begin.
case
management
A utilization management technique that addresses the
medical necessity of care as well as alternative treatments
or solutions, especially when the patient is likely
to require very expensive treatment.
certificate
of insurance
A document that describes the type and length of coverage
provided by a group insurance policy that is given to
each insured by the group policyholder.
chiropractic
care
Not all plans cover chiropractors -- practitioners who
manipulate the spine and other structures within the
body to relieve pain and tension resulting from posture,
stress or strain. Some plans offer chiropractic care
as an optional benefit.
claim
A request for payment under the terms of an insurance
policy.
claim
examiner
An insurance company employee who is responsible for
carrying out the claim examination process. Also known
as claim approver, claim analyst, or claim specialist.
coinsurance
provision
A specified percentage of the cost of treatment the
insured is required to pay for all covered medical expenses
remaining after the policy's deductible has been met.
commission
The amount of money, usually a percentage of the premiums,
that is paid to an insurance agent for selling an insurance
policy.
comprehensive
major medical policy
A health insurance policy that covers both major medical
coverages (i.e., hospitalization and surgeries) and
basic medical expense coverages.
copay
(1) A fee that many insurance plans require an insured
to pay for certain medical services (such as a physician's
office visit). (2) An amount that the insured must pay
toward the cost of each prescription under a prescription
drug plan.
D
deductible
A flat amount of covered medical expenses that an insured
must incur before the insurer will make any benefit
payments under a medical expense policy.
dental
-- benefits
Some health plans offer dental care as an optional benefit
or rider that you or your employees may decide to add
at an additional cost.
dependent
A person for whom the insured has some legal obligation
to. For most plans, it is the insured's spouse and/or
children. Some plans also allow non-traditional spousal
relationships (significant other, life-partner, etc.)
to be considered a dependent with some additional certifying
paperwork.
domestic
partner
Domestic partners are commonly defined as "two
adults who share an emotional, physical and financial
relationship similar to that of a married couple but
who either choose not to marry or cannot legally marry.
They share a mutual obligation of support for the basic
necessities of life." Additionally, some carriers
may require that domestic partners own property together
to qualify.
dual
choice
Dual choice allows the employer to offer his employees
not one, but two health plans. Instead of picking the
least expensive plan for all employees, Dual Choice
lets employees choose the type of plan that best meets
their needs or budgets. Usually, this is a choice of
an HMO and PPO, or HMO and POS. The employer will typically
pay a portion of the premium in these plans, and the
employee will pay the balance. Here are a few approaches:
- An employer may pay for the lower cost plan and
employees may buy up to the more expensive plan.
- An employer may pay a set amount per month for
every employee.
- An employer may charge all employees the same
amount and pay the balance, regardless of the plan
each employee selects.
E
effective
date
The specified date of when the health insurance policy
is to begin.
emergency
care
Most plans cover emergency care in a hospital emergency
room if it is an extremely urgent medical emergency,
even if the hospital you are taken to is not in the
plan's network. It is possible, however, that after
your condition has been stabilized, you would be transferred
to a participating plan hospital.
emergency-room
visit
A visit to a hospital for treatment of an accidental
injury or for emergency medical care. To qualify as
an emergency, the symptoms must be sudden, severe and
require immediate medical attention. Some states judge
emergencies by the "prudent layperson" law,
meaning that the health plan must cover a trip to the
emergency room "if a prudent layperson, acting
reasonably, would have believed that an emergency medical
condition existed." Keep in mind that some plans
won't cover a trip to the emergency room if the symptoms
appeared more than 24 hours earlier.
employee
contribution
The amount of premium the employer requires the employee
to pay towards his or her health insurance.
enrollment
or eligibility period
The time during which a new group member may first enroll
for group insurance coverage.
exclusions
and limitations
Conditions, situations and services not covered by the
health plan.
F
fee
schedule payment structure
A fee structure used by insurers under which the insurance
company places caps or limits on the dollar amounts
that it will reimburse providers covered medical procedures
and services, both in and out-of-network if applicable.
Also known as a limited fee schedule.
fee-for-service
plan
Also called an indemnity plan. A health insurance plan
that allows the insured to use any medical provider
that he or she chooses. As such, there are no networks
to utilize.
flex-term
medical coverage
See "short-term medical coverage."
formulary
drugs
Formulary drugs generally have a lower copay. A formulary
drug is one that has been thoroughly reviewed by a team
of expert pharmacists and physicians; these drugs have
been identified as safe, effective and beneficial to
members for treating medical conditions. When deciding
between drugs which are equally safe and effective,
the formulary team also considers the relative costs
of medications. These savings are then passed on to
you through lower premiums.
fully
insured plan
A group insurance plan for which an insurance company
bears the responsibility of making all claim payments.
fully
self-insured plan
A group insurance plan under which the employer takes
complete responsibility for all claim payments and related
expenses rather than purchasing coverage from an insurance
company.
G
gatekeeper
A term used to describe the primary care physician's
role in a managed care plan; this role is to authorize
all services delivered to the insured by other physicians
or health care providers. Thus, whenever you wish to
see a physician other than your primary care physician,
you must first obtain his or her permission (via a referral).
generic
(medications)
When a new drug is put on the market, the pharmaceutical
company patents it under a brand name. The company has
the exclusive right to sell the drug under this name,
but once its patent expires, other companies can sell
the same drug under its chemical, or generic, name.
Generic drugs are typically cheaper than brand-name
drugs, but the Food and Drug Administration requires
generic drug manufacturers to show that a generic drug
"delivers the same amount of active ingredient
in the same time frame as the original product."
group
term life
A life-insurance plan that provides employees with additional
coverage at economical group rates.
guaranteed
renewable policy
A health insurance policy that the insurer is required
to renew -- as long as premiums are paid -- at least
until the insured attains the age limit specified in
the policy, or the policy is cancelled by the insured.
The insurer may increase the premium rate for any class
of guaranteed renewable policies.
H
health
care provider
A doctor, hospital, laboratory, nurse or anyone else
who delivers medical or health-related care.
health
insurance
A type of insurance that provides protection against
the risk of financial loss resulting from the insured
person's sickness, accidental injury or disability.
health
insurance portability and accountability act of 1996
(HIPAA)
Under this federal law (known as HIPAA), group health
plans cannot deny coverage based soley on an individual's
health status. This law also gives employees who change
or lose their jobs better access to health coverage,
guarantees renewability and availability to certain
employees and limits exclusions for pre-existing conditions.
For example, under this law, group health plans must
credit any employee the amount of time that they spent
on any health plan prior to the new plan, which is known
as "prior credible coverage." A pre-existing
condition will be covered without a waiting period when
an employee joins a new group plan if the employee has
been insured for the previous 12 months with credible
health insurance, with no lapse in coverage of 63 days
or more. This means that if an employee has been insured
for 12 months or more, the employee will be able to
go from one job to another and his or her pre-existing
coverage will remain intact -- without additional waiting
periods. However, if an employee has a pre-existing
condition and was not covered previously for 12 months
before joining a new plan, the longest the employee
will have to wait for their pre-existing coverage to
be covered is 12 months.
health
maintenance organization (HMO)
A health care financing and delivery system that provides
comprehensive health care for subscribing members in
a particular geographic area using managed care techniques.
Most HMOs require that you only utilize physicians within
their network, often going so far as to require you
to choose a primary care physician who directs most
courses of your treatment.
home
health care
Skilled medical care and other health care services
that you receive in your home for the treatment of an
illness or injury. Some insurance plans don't provide
this kind of coverage, or provide it only for a limited
amount of time.
I
indemnity
plan
Also called a fee-for-service plan. A health insurance
plan that allows the insured to use any medical provider
that he or she chooses. As such, there are no networks
to utilize.
individual
practice association (IPA)
A type of open-panel HMO that contracts with an association
of physicians who agree to provide services for HMO
members.
inpatient
surgery
Medical procedures which require the patient to spend
at least one night at the hospital. Most plans limit
the amount of time an inpatient may stay at the hospital
following surgery.
insurance
agent
A person authorized by an insurance company to represent
the company in its dealings with applicants for insurance.
insured
The person whose life or health is insured under an
insurance policy. Also referred to as a "member."
J
Sorry, we have no glossary items beginning
with the letter J.
K
Sorry, we have no glossary items beginning
with the letter K.
L
life
dependent
This option is offered by some plans to provide a set
amount of life insurance for the insured's spouse, domestic
partner or children.
lifetime
maximum
The maximum amount of money a plan will pay towards
healthcare services over the course of the insured's
lifetime.
