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Glossary for Health Insurance Terms

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Access It means the availability of medical care to a consumer.
Accumulation Period It is the period of time during which an insured consumer incurs eligible medical expenses to satisfy the condition of a deductible.
Actively-at-work It is a condition applicable to the employees. If an employee is not "actively-at-work" on the day the policy goes into effect, the coverage does not start until the employee returns to work.
Actual Charge It is the actual dollar amount charged by a physician/provider for rendered service. It is different from the allowable charge.
Actuary It means a professional trained to calculate premium rates, reserves and dividends.
Acupuncture It is the service performed by a licensed acupuncturist.
Acute Care It is the medical care for the treatment of a serious injury or illness or during recovery from surgery.
Age Change It is the date on which a consumer's age changes. It may be different from the actual birthday. It often results in premium rise.
Age Limits It refers to the limits of age on which insurance company will not accept applications or renew policies.
Agent Agent is a state-licensed entity who represents one or more insurance companies.
Allowable Charge It is the dollar amount considered payment-in-full by an insurance company.
Allowable Costs These are charges for healthcare services and supplies which are covered in the health insurance plan.
Alternative Medicine It is a system of medical treatment practice not recognized as effective by the medical community at large. It includes acupuncture, homeopathy, aromatherapy, naturopathy, etc.
Ancillary Fee It is an extra fee to obtain prescription drugs not listed on a health insurance plan's formulary of covered medications.
Ancillary Products It means the additional products that may be added to an surance plan for an additional fee, including vision and dental cover.
Ancillary Services It means the supplemental healthcare services provided in conjunction with medical care.
Application Fee It is the one-time fee required by insurance companies.
Approved Health Care Facility or Program It refers to the medical facility of healthcare program approved by a health insurance plan.
Assignment of Benefits It is the payment of benefits to a healthcare provider rather than to the consumer.
   
Balance Billing It is the amount a consumer needs to pay when an out-of-network provider is used. If the fee exceeds the allowable charge for a service, it becomes payable by the consumer.
Benefit It refers any service or supply covered by a health insurance plan.
Benefit Level It is the maximum amount that a health insurance company pays for a particular covered service.
Benefit Package It is the description of the healthcare services and supplies that are offered in a specific insurance plan.
Benefit Riders It is a term used to describe ancillary products purchased along with a health insurance plan.
Benefit Year It is the annual cycle of time in which a health insurance plan operates.
Binding Receipt It is an indication meaning if the coverage is approved the coverage needs to be initiated from the date on which payment was received.
Birthday Rule It refers to a technique to determine which who should be the primary coverage provider when both parents of a dependent child have separate coverages. In most cases, the earliest birthday in the year will be considered primary.
Broker A broker matches applicants with a health insurance company or plans according to their needs.
   
COB (Coordination of Benefits) It is the process to determine whether the insurance company should be the primary or secondary payer for a patient who has more than one health insurance policies.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) It is a Federal legislation allowing an employee or an employee's dependents to retain group health insurance coverage at the individual's expense, for up to 18 months in certain circumstances. There are further options available for extension.
Capitation It refers to a method that pays a healthcare provider on a per-patient rather than a per-service basis.
Carrier It is a term ascribed to an insurer, managed care organization, or group hospital plan.
Centers for Medicare and Medicaid Services These centers are responsible for the administration of the Medicare and Medicaid programs.
Certificate of Coverage It is a document given to an insured consumer that details the benefits, limitations and exclusions of coverage provided.
Chiropractic It is a service including services provided by a licensed chiropractor.
Claim It is a bill for services rendered and submitted to the insurance company by a healthcare provider.
Coinsurance It is the amount that a consumer pays for services after co-payment or deductible have been exhausted in terms of percentage of the allowable charge for a service rendered by a healthcare provider.
Company It is the insurance body that is offering the health insurance plan.
Co-payment It is the charge that a consumer needs to pay for a specific medical service or supply, also referred to as a "co-pay."
   
Date of Service It it the date on which a healthcare service was provided.
Deductible It is the dollar amount that a consumer pays out-of-pocket each year before the health plan actually begins to make payments for claims.
Dependent Coverage It is the coverage for the spouse and unmarried children of a primary insured consumer.
Designated Mental Health Provider It is the organization hired by a health insurance plan to provide mental health services.
Drug Formulary It is the list of prescription medications selected for coverage under an insurance plan based upon the efficacy, safety and cost-effectiveness of the drugs.
   
ERISA (Employment Retiree Income Security Act of 1974) It is the Federal legislation that protects the rights of retirees and beneficiaries.
Effective Date It is the date on which health insurance coverage starts.
Eligibility Date It is the date on which insurance benefits are offered to an eligible consumer.
Eligibility Requirements These are the conditions necessary for an individual or group to qualify for insurance coverage.
Eligible Dependent It means the dependent of an insured person eligible for coverage.
Eligible Employee It means the employee eligible for insurance coverage under a group health insurance plan.
Eligible Expenses These are costs eligible for coverage.
Eligible Person It is a term designating a consumer eligible for insurance coverage.
Emergency Room It is a set of services including a patient's visits to an emergency room for an emergency condition.
Employee Contribution It is the portion of the health insurance premium paid by the employee.
Employer Contribution It is the portion of premium paid for by the employer.
Enrollee It means an eligible consumer or eligible employee who is enrolled in a health insurance plan.
Enrollment It is the process that helps an approved applicant to be signed up with the health insurance company.
Enrollment Period It is the time period during which an eligible consumer may sign up for a group health insurance plan.
EPO (Exclusive Provider Organization) As a member of an EPO, a consumer is eligible to use the doctors and hospitals within the EPO network, but there are no out-of-network benefits.
Estimated Cost It is the estimated cost of the health plan. This cost depends on various parameters including, medical history, the underwriting practices, the optional benefits selected, and other factors related to the consumer.
Evidence of Insurability A consumer is asked to write the health condition in writing through a questionnaire or a medica examination. However, it is required in specific cases for a group health insurance.
Exclusions These are specific conditions, services or treatments for which coverage is not provided.
Explanation of Benefits (EOB) It is a statement sent by the insurance company to a consumer listing services that were billed by a provider.
Extended Coverage It refers to the coverage offered after the member is no longer covered, e.g. maternity benefits.
Extension of Benefits It is extention of coverae beyond a scheduled termination date if the consumer is disabled or hospitalized. It continues till the patient leaves the hospital or returns to work.
   
Gatekeeper It is a term describing the role of the primary care physician in an HMO plan.
Generic Drug It is type of a drug, which is same as a brand name prescription drug; however, it is open for production by other manufacturers after the brand name drug's patent has expired.
Grace Period It is the period of time after the payment due date, during which coverage remains effective allowing the consumer to make a payment without penalty.
Grievance Procedure It is the procedure used to file a complaint with a health insurance company for remedy.
Group It means a number of individuals covered under a single health insurance plan.
Group Health Insurance It is a health insurance plan providing benefits to employees of a business or members of an organization.
Guaranteed Issue It means the insurance coverage that must be issued regardless of health status.
Guaranteed Renewable Contract It is a contract that arms an insured consumer to renew the health insurance policy by the timely payment of premiums up to certain age limit.
   
HIPAA (Health Insurance Portability and Accountability Act of 1996) It is a legislation that mandates specific privacy rules and practices for medical care providers and health insurance companies to protect the privacy and identity of healthcare consumers.
HMO (Health Maintenance Organization) It is a type of a health insurance plan that offers health care services through a network of providers. These providers contract exclusively with the HMO, or agree to provide services to members at a pre-negotiated rate.
HSA (Health Savings Account) It is a tax advantaged savings used along with high-deductible health insurance plans to pay for qualifying medical expenses.
Health Service Agreement It is an agreement between an employer and a health insurance company outlining the benefits, enrollment procedures, eligibility standards, etc.
Hospice Care It is a type of care rendered for a terminally ill patient.
Hospitalization It includes services offered while staying at a hospital. The reason might include scheduled procedures, accidents or medical emergencies. Maternity may not be counted in this.
Hospitalization Insurance It is the insurance to provide coverage in case of hospitalization.
   
In-area Services These are the healthcare services offered within the coverage area of a health insurance plan.
Indemnity Plan It is type of a plan that allows the consumer to visit whatever doctors or hospitals it wants.
Integrated Delivery System It means a group of doctors, hospitals and other providers working together to deliver healthcare services to the patients.
   
Lab/X-Ray Lab services include services like blood panels and urinalysis; while X-ray services include basic outpatient skeletal or other plain film x-ray, outpatient ultrasound, GI series, MRI, and CT scan.
Lapse It means the termination of coverage due to non-payment after a specific period of time.
Length of Stay (LOS) It means the total number of days that a patient stays in a hospital.
Lifetime Maximum It is the maximum dollar amount agreed by a health insurance company to cover a consumer during his or her lifetime.
Limitations It is a term used to express any maximums regarding to the benefits offered in a plan.
Long-term Care It is a type of care provided for the chronically ill or disabled.
   
MSA (Medical Savings Account) It is a type of tax-advantaged account used along with a high-deductible health insurance plan.
Managed Care It is a term that indicates healthcare and health insurance systems attempting the use of benefits through a primary care physician, or through a specific network of healthcare providers.
Maternity Coverage It is the insurance that covers part or all of the medical cost during a woman's pregnancy.
Max Duration It is the longest coverage period offered by a health insurance plan.
Maximum Out-Of-Pocket Costs It is the total maximum amount that a consumer will pay out-of-pocket in a benefit year.
Medicaid It is a state-funded healthcare program for low income and disabled persons.
Medicare It is a federally-administered health plan covering hospitalization, medical care, and some health services for most people over age 65 and certain other eligible individuals.
Medicare Beneficiary It means a consumer entitled to Medicare benefits based.
Medicare Supplement Insurance It is a type of insurance that helps during the gaps in Medicaid coverage.
Member It means a person covered under a health insurance plan.
   
National Association of Insurance Commissioners (NAIC) It is an association of officials that regulates insurance to provide measures of national uniformity in insurance regulation.
Network It means the set or doctors, hospitals, and facilties that are allowed to be used in a managed care plan.
Network Provider It means a healthcare provider who holds a contract with a health insurance company.
Nursing Home It is a licensed facility providing general nursing care to chronically ill or needing constant supervision and assistance.
   
Office Visit It means the amount a consumer pays when he/she sees the doctor or dentist for routine care. 
Open Enrollment Period It is the time period during which a consumer may opt to sign up for coverage under a group health insurance plan.
Out-of-network Care It means the healthcare offered outside of the health insurance company's network of preferred providers.
Out-of-pocket Costs It means the total costs payable by a consumer out of his or her own pocket, including coinsurance, deductibles, etc..
Over-the-counter (OTC) Drugs It means the drugs that may be obtained without a prescription.
   
POS (Point of Service) It is a type of a plan that combines elements of both HMO and PPO plans.
PPO (Preferred Provider Organization) It is a type of a plan in which a consumer needs to get the medical care from doctors or hospitals on the insurance company's list of preferred providers if the consumer wants the claims to be paid at the highest level.
Part-Time Employee It is a term referring an employee who is working between 20-29 hours per week.
Partial Hospitalization Services It is term used to refer to outpatient services performed in a hospital setting.
Participating Provider It is a term used in synonymous with Network Provider.
Periodic Health Exam It is an exam occuring regularly for preventative purposes, like a routine physical or annual check-up.
Periodic OB-GYN Exam It is an exam occuring regularly for preventative purposes, like a PAP smear.
Place of Service It means the type of facility in which healthcare services were provided.
Policy Form Number It is a number that identifies each health insurance policy filed with a state's department of insurance.
Policy Term It is the time period for which a health insurance policy provides coverage.
Pre-existing Condition It is a health problem that existed or was treated before the effective date of the health insurance coverage.
Pre-existing Condition Exclusion It is an option for a health insurance company to exclude a pre-existing conditions from coverage under a new health insurance plan.
Premium It means the total amount paid to the insurance company for health insurance coverage.
Prescription Medication It refers to drugs obtainable only with a doctor's prescription and approved by the Food and Drug Administration.
Prescription Drug Coverage It refers to coverage provided for prescription drugs to be used by the consumer.
Preventive Care It refers to the medical care rendered focusing on prevention and early-detection of disease.
Primary Coverage It refers to a condition where If a person is covered by more than one health insurance plan, the plan paying first means the primary coverage.
Provider It refers to any healthcare provider, whether a doctor or nurse, a hospital or clinic.
   
Qualifying Event It is an event that triggers a group health insurance member's protection under COBRA.
   
Rating Process It is the process by which a premium or rate for a group is determined.
Referral It is the process used by primary care physician approving a consumer to see a specialist.
Renewal It means a condition which occurs when a member continues the coverage beyond the original time frame of the contract.
Renewal Date It refers to the date on which a consumer's health insurance plan benefit year renews.
Rider It refers to an amendment or modification to an insurance contract.
   
Secondary Coverage It is the coverage offered after the payment made by the primary coverage.
Service Area It refers to the geographic area in which a health insurance plan's benefits are made available.
Short-term Plans It means the plans that offers coverage for no more than 6 months. The benefits are less comprehensive as compared to a regular health insurance plan.
Specialist It means a doctor who does not serve as a primary care physician but specializes in a specific medical field.
Subrogation It is a process used to determine whether bills should be paid by the health insurance company or by another insurer or third party.
   
Terminally Ill It is a term used to describe a person not expected to live beyond six months due to a specific illness.
Treatment Facility It means a residential or non-residential facility authorized to provide treatment for mental illness or substance abuse.
   
Underwriting It is the process to determine whether a health insurance company will accept an application for insurance.
Usual, Customary and Reasonable (UCR) Charge It means the most common charge for a particular medical service rendered in a specific geographic area.
Vision Care Coverage It means the coverage offered only on a group basis covering routine eye examinations and costs associated with contact lenses or eyeglasses.
   
W-2 It is a federal tax form used to report an employee's wages and taxes.
Waiting Period It is the time during which the health insurance plan does not provide benefits for pre-existing conditions.
Waiver of Premium It means allowing a consumer to maintain health insurance coverage in full force without payment in cases of permanent and total disability.