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
employed 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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