Advocacy:
Any activity done to help a person or group to get something the person or group
needs or wants.
Association:
A group. Often, associations can offer insurance plans specially designed for
their members.
Benefit:
Amount payable by the insurance company to a claimant,
assignee, or beneficiary when the insured suffers a loss.
Capitation:
Capitation represents a set dollar limit that you or
your employer pay to a health maintenance organization (HMO), regardless of how
much you use (or don't use) the services offered by the health maintenance
providers. (Providers is a term used for health professionals who provide care.
Usually providers refer to doctors or hospitals. Sometimes the term also refers
to nurse practitioners, chiropractors and other health professionals who offer
specialized services.)
Case Management:
Case management is a system embraced by employers and insurance companies to
ensure that individuals receive appropriate, reasonable health care services.
Claim:
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.
Co-Insurance:
Co-insurance refers to money that an individual is
required to pay for services, after a deductible has been paid. In some health
care plans, co-insurance is called "co-payment." Co-insurance is often specified
by a percentage. For example, the employee pays 20 percent toward the changes
for a service and the employer or insurance company pays 80 percent.
Co-Payment:
Co-payment is a predetermined (flat) fee that an
individual pays for health care services, in addition to what the insurance
covers. For example, some HMOs require a $10 "co-payment" for each office visit,
regardless of the type or level of services provided during the visit.
Co-payments are not usually specified by percentages.
Deductible:
The amount an individual must pay for health care
expenses before insurance (or a self-insured company) 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 (or his or her provider) to pay for health care
services obtained from a health care professional.
Dependent Worker:
A worker in a family in which someone else has
greater personal income.
Employee Assistance Programs (EAPs):
Mental health counseling services that are sometimes offered by insurance
companies or employers. Typically, individuals or employers do not have to
directly pay for services provided through an employee assistance program.
Exclusions:
Medical services that are not covered by an
individual's insurance policy.
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 (HMO's):
Health Maintenance Organizations represent "pre-paid" or "capitated" insurance
plan in which individuals or their employers 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 employeed by, or under contract
with, the HMO. HMOs vary in design. Depending on the type of the HMO, services
may be provided in a central facility, or in a physician's own office (as with
IPAs.)
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 individual pays a pre-determined percentage of
the cost of health care services, and the insurance company (or self-insured
employer) pays the other percentage. For example, an individual might pay 20
percent for services and the insurance company pays 80 percent. The fees for
services are defined by the providers and vary from physician to physician.
Indemnity health plans offer individuals the freedom to choose their health care
professionals.
Independent Practice Associations:
IPAs are similar to HMOs, except that individuals receive care in a physician's
own office, rather than in an HMO facility.
Long-Term Care Policy:
Insurance policies that cover specified
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.
LOS:
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.
Managed Care:
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 (or self-insured company) will pay for claims within a
specific time period. Maximum dollar limits vary greatly. They may be based on
or specified in terms of types of illnesses or types of services. Sometimes they
are specified in terms of lifetime, sometimes for a year.
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.
Open-ended HMOs:
HMOs which allow enrolled individuals to use out-of-plan providers and still
receive partial or full coverage and payment for the professional's services
under a traditional indemnity plan.
Out-Of-Plan:
This phrase usually refers to physicians, hospitals or other health care
providers who are considered nonparticipants in an insurance plan (usually an
HMO or PPO). 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.
Out-Of-Pocket Maximum:
A predetermined limited amount of money
that an individual must pay out of their own savings, before an insurance
company or (self-insured employer) will pay 100 percent for an individual's
health care expenses.
Outpatient:
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.
Pre-Admission Certification:
Also called pre-certification
review, or pre-admission review. Approval by a case manager or insurance company
representative (usually a nurse) for a person to be admitted to a hospital or
in-patient facility, granted prior to the admittance. Pre-admission
certification often must be obtained by the individual. Sometimes, however,
physicians will contact the appropriate individual. The goal of pre-admission
certification is to ensure that individuals are not exposed to inappropriate
health care services (services that are medically unnecessary).
Pre-Admission Review:
A review of an individual's health care
status or condition, prior to an individual being admitted to an inpatient
health care facility, such as a hospital. Pre-admission reviews are often
conducted by case managers or insurance company representatives (usually nurses)
in cooperation with the individual, his or her physician or health care
provider, and hospitals.
Preadmission Testing:
Medical tests that are completed for an
individual prior to being admitted to a hospital or inpatient health care
facility.
Pre-existing Conditions:
A medical condition that is excluded
from coverage by an insurance company, because the condition was believed to
exist prior to the individual obtaining a policy from the particular insurance
company.
Preferred Provider Organizations (PPOs):
You or your employer 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. Typically, a PCP serves as a "quarterback" for an individual's
medical care, referring the individual to more specialized physicians for
specialist care.
Provider:
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. If the fees are higher than the approved amount, the
individual receiving the service is responsible for paying the difference.
Sometimes, however, if an individual questions his or her physician about the
fee, the provider will reduce the charge to the amount that the insurance
company has defined as reasonable and customary.
Risk:
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. For example, an individual increases his
or her risk of getting cancer if he or she chooses to smoke cigarettes.
Second Opinion:
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.
Second Surgical Opinion:
These are now standard benefits in many
health insurance plans. It is an opinion provided by a second physician, when
one physician recommends surgery to an individual.
Short-Term Disability:
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.
Triple-Option:
Insurance plans that offer three options from
which an individual may choose. Usually, the three options are: traditional
indemnity, an HMO, and a PPO.
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.
Waiting Period:
A period of time when you are not covered by
insurance for a particular problem.
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