Glossary of Health Insurance Terms
Commonly used terms and phrases used by people in the insurance industry.
A
ADL
See Activities of Daily Living Standards.
A&H, A&S. Accident and Health Insurance, Accident and Sickness Insurance
Once commonly used as generic designations for the entire field now called Health Insurance. See Health Insurance.
Accelerated BenefitsRiders on life insurance policies which allow the life insurance policy's death benefits to be used to offset expenses incurred in a convalescent or nursing home facility.
Access
The availability of timely medical care to a patient. This can be determined by location, transportation, type of medical services in the area, etc.
Accident and Health Insurance (A&H)An older name for Health Insurance. See Health Insurance.
Accident and Sickness Insurance (A&S)An older name for Health Insurance. See Health Insurance.
Accident Insurance
A form of insurance against loss by accidental bodily injury to the insured.
Accidental Death and DismembermentA policy or a provision in a Disability Income policy which pays either a specified amount or a multiple of the weekly disability benefit if the insured dies, loses his or her sight, or loses two limbs as the result of an accident. A lesser amount is payable for the loss of one eye, arm, leg, hand, or foot.
Accidental Death BenefitAn extra benefit which generally equals the face of the contract or principal sum, payable in addition to other benefits in the event of death as the result of an accident. See also Double Indemnity and Multiple Indemnity.
Accidental Death Insurance
A form that provides payment if the death of the insured results from an accident. It is often combined with Dismemberment Insurance in a form called Accidental Death and Dismemberment. See also Accidental Death and Dismemberment.
Accredited (Accreditation):
A "seal of approval" for health care facilities. Being accredited means that a facility has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at health care facilities.
Accumulation Period:Timeframe within a policy period in which deductible and out-of-pocket amounts are calculated. For most health insurance policies, the accumulation period is a calendar year.
Actively-at-work
Most group health insurance policies state that if an employee is not actively at work on the day the policy goes into effect, the coverage will not begin until the employee does return to work.
Activities of Daily Living (ADL)Everyday living functions and activities performed by individuals without assistance. These functions would include mobility, dressing, personal hygiene and eating.
Activities of Daily Living (ADL) Standards
Used to assess the ability of an individual to live independently, measured by the ability to perform unaided such activities as eating, bathing, toiletry, dressing, and walking. ADL standards are sometimes discussed as a way to measure or define eligibility for long term care.
Actual Charge
The actual amount charged by a physician for medical services rendered.
Acute CareSkilled, medically necessary care provided by medical and nursing personnel in order to restore a person to good health.
Additional Drug Benefit List
Prescription drugs listed as commonly prescribed by physicians for patients' long-term use. Subject to review and change by the health plan involved. Also called drug maintenance list.
Additional Monthly BenefitRiders added to disability income policies to provide additional benefits during the first year of a claim while the insured is waiting for Social Security benefits to begin.
Adjusted Average Per Capita Cost (AAPCC)The estimated average cost of Medicare benefits established on a per county basis _ factors include age, sex, Medicaid, institutional status, disability, and end stage renal disease status. Used to determine payments to cost contractors for Medicare benefits.
Adjusted Community Rating (ACR)
Community rating adjusted by factors specific to a particular group. Also known as factored rating.
Administrative Services Only (ASO) contractThe contract between an employer and a third party administrator. These services typically include health claims processing and billing. The employer bears the risk for health care expenses under an ASO plan.
Admissions/1,000The number of hospital admissions for each 1,000 members of the health plan.
AdmitsThe number of admissions to a hospital (including outpatient and inpatient facilities).
Admitting Physician
The doctor responsible for admitting you to a hospital or other inpatient health facility.
Admitting Privileges
The right granted to a doctor to admit patients to a particular hospital.
Adult Day Care
A group program for functionally impaired adults, designed to meet health, social and functional needs in a setting away from the adult's home.
Aftercare
Individualized patient services required after hospitalization or rehabilitation.
Age Change
The date on which a person's age, for insurance purposes, changes. In most Life Insurance contracts this is the date midway between the insured's natural birth dates. Health insurers frequently use the age of the previous birth date for rate determinations. On the date of age change, a person's age may change to that of the last birth date, the nearer birth date, or the next birth date, depending upon the way in which the rating structure has been established by that particular insurer.
Age/Sex Factor
Compares the age and sex risk of medical costs of one group relative to another. An age/sex factor above 1.00 indicates higher than average risk of medical costs due to that factor. Conversely, a factor below 1.00 indicates a lower than average risk. This measurement is used in underwriting.
Age/Sex Rates (ASR)
Separate rates are established for each grouping of age and sex categories. Preferred over single and family rating because the rates and premiums automatically reflect changes in the age and sex content of the group. Also sometimes called table rates.
Aggregate Indemnity
A maximum dollar amount that may be collected by the claimant for any disability, for any period of disability, or under the policy as a whole.
Aggregate stop-loss coverage.
A type of stop-loss insurance that provides benefits when a group's total claims during a specified period exceed a stated amount.
Allied Health Personnel
Health personnel who perform duties which would otherwise have to be performed by physicians, optometrists, dentists, podiatrists, nurses, and chiropractors. Also called paramedical personnel.
Allocated BenefitsPayments authorized for specific purposes with a maximum specified for each. In hospital policies, for instance, there may be scheduled benefits for X-rays, drugs, dressings, and other specified expenses.
Allowable Charge
The lesser of the actual charge, the customary charge and the prevailing charge. It is the amount on which Medicare will base its Part B payment.
Allowable Costs
Charges which qualify as covered expenses.
Alternative Delivery SystemsSystems which cover health care costs, other than on the usual fee-for-service basis. Could include HMOs, IPAs, PPOs, etc.
Alzheimer's Disease
A progressive, irreversible disease characterized by degeneration of the brain cells and severe loss of memory causing the individual to become dysfunctional and dependent upon others for basic living needs.
Ambulatory CareSimilar to outpatient treatment in that it is care which does not require hospitalization.
Ambulatory Care Facility (ACF)
A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center
Ancillary
Additional services (other than room and board charges) such as X-rays, anesthesia, lab work, etc. Fees charged for ancillary care such as X-rays, anesthesia, and lab work. This term may also be used to describe the charge made by a pharmacy for prescriptions which exceed the health insurance plan's maximum allowable cost (MAC).
Ancillary Benefits
Benefits for miscellaneous hospital charges
Appeal
Request made to a payer to reconsider a decision, such as a claim denial or denied prior authorization request. Most appeals must be submitted in writing within a specified period.
Appropriateness Review
An analysis of healthcare services with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided.
Approved Charge
Amounts paid under Medicare as the maximum fee for a covered service.
Approved Health Care Facility or ProgramA facility or program which has been approved by a health care plan as described in the contract.
Assignment
An authorization to pay Medicare benefits directly to the provider. Medicare payments may be assigned to participating providers only.
Assignment of BenefitsA method where the person receiving the medical benefits assigns the payment of those benefits to a physician or hospital.
ASO contractSee administrative services only contract.
Average Cost Per Claim
The total cost of administrative and/or medical services divided by the number of units of exposure such as costs divided by number of admissions, or cost divided by number of outpatient claims, etc.
Average Length of Stay (ALOS)
The total number of patient days divided by the number of admissions and discharges during a specified period of time. This gives the average number of days in the hospital for each person admitted.
Average Wholesale Price (AWP)
Under the Medicare catastrophic coverage act, payment for prescription drugs is limited to the lowest of the pharmacy's actual charge, the sum of the AWP for the drug plus an administrative allowance, or effective 1992, the 90th percentile of pharmacy charges.
B
Base Capitation
The total amount which covers the cost of health care per person, minus any mental health or substance abuse services, pharmacy, and administrative charges.
Basic Hospital Expense Insurance
Hospital coverage providing benefits for room and board and miscellaneous hospital expenses for a specified number of days during hospital confinement.
Bed Days/1,000
The number of inpatient hospital days per 1,000 members of the health plan.
Benefit Levels
The maximum amount a person is entitled to receive for a particular service or services as spelled out in the contract with a health plan or insurer.
Benefit Period
Defines the period during which a Medicare beneficiary is eligible for Part A benefits. A benefit period is 90 days which begins the day the patient is admitted to a hospital and ends when the individual has not been hospitalized for a period of 60 consecutive days.
Billed Claims
The amounts submitted by a health care provider for services provided to a covered individual.
Binding Receipt
See Conditional Binding Receipt.
Birthday Rule
One method of determining which parent's medical coverage will be primary for dependent children: the parent whose birthday falls earliest in the year will be considered as having the primary plan.
Blanket Insurance
A contract of Health Insurance that covers all of a class of persons not individually identified in the contract.
Blanket Medical Expense
A policy or provision in a Health Insurance contract that pays all medical costs, including hospitalization, drugs, and treatments, without limitation on any item except possibly for a maximum aggregate benefit under the policy. It is often written with an initial deductible amount.
Blue Cross
Blue Cross plans are nonprofit hospital expense prepayment plans designed primarily to provide benefits for hospitalization coverage, with certain restrictions on the type of accommodations to be used.
Blue Plan
A generic designation for those companies, usually writing a service rather than a reimbursement contract, who are authorized to use the designation Blue Cross or Blue Shield and the insignia of either.
Blue Shield
Blue Shield plans are prepayment plans offered by voluntary nonprofit organizations covering medical and surgical expenses.
Board Certified
A physician or other professional who has passed an examination which certifies him or her as a specialist in a particular medical area.
Board Eligible
A professional person or physician who is eligible to take a specialty examination.
Business Overhead Expense
A disability income policy which indemnifies the business for certain overhead expenses incurred when the business owner is totally disabled.
C
COB
Coordination of Benefits. See Nonduplication of Benefits.
COBRA
See Consolidated Omnibus Budget Reconciliation Act of 1986.
Calendar Year
January 1 through December 31 of the same year. Many deductible amount provisions are on a calendar year basis under major medical plans. Also, benefits under basic hospital surgical and medical plans are usually stated as so much for each calendar year.
Capitation (CAP)
A rate paid, usually monthly, to a health care provider. In return, the provider agrees to deliver the health services agreed upon to any covered person.
Carrier
A commercial insurer
Carrier Replacement
This refers to a situation where one carrier replaces one or more carriers.
Carry Over Provision
In major medical policies, allowing an insured who has submitted no claims during the year to apply any medical expenses incurred in the last three months of the year toward the new calendar year's deductible.
Case Management
The assessment of a person's long term care needs and the appropriate recommendations for care, monitoring and follow-up as to the extent and quality of services to be provided.
Case Manager
A person, usually an experienced professional, who coordinates the services necessary under the case management approach.
Case Mix
The number of cases requiring different needs and uses of hospital resources.
Catastrophe Policy
This is an older name for Major Medical. See Major Medical.
Cestui Que Vie
The person whose life measures the duration of a trust, gift, estate, or insurance contract. Thus, in Life and Health Insurance it is the person on whose life or health the policy is written, commonly called the insured, policyholder, or policy owner.
Chemical Dependency Services
The services required in the treatment and diagnosis of chemical dependency, alcoholism, and drug dependency.
Chemical Equivalents
Drugs which contain identical amounts of the same ingredients.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Part of the Uniformed Services Health Benefits Program which supplements the medical care available for families of active, deceased, and retired military personnel.
Closed Access
A situation where covered insureds must select one primary care physician. That physician is the only one allowed to refer the patient to other health care providers within the plan. Also called Closed Panel or Gatekeeper model.
Cognitive Impairment
A deficiency in the ability to think, perceive, treason or remember resulting in loss of the ability to take care of one's daily living needs.
Coinsurance Clause
A provision stating that the insured and the insurer will share all losses covered by the policy in a proportion agreed upon in advance, i.e., 80-20 would mean that the insurer would pay 80% and the insured would pay 20% of all losses.
Commercial Policy
In Health Insurance, this term originally applied to policy forms intended for sale to individuals in commerce, as contrasted with industrial workers. Currently the term is loosely used to mean all policies that do not guarantee renewability.
Community Rating
Under this rating system, the charge for insurance to all insureds depends on the medical and hospital costs in the community or area to be covered. Individual characteristics of the insureds are not considered at all.
Composite Rate
One rate for all members of the group regardless of their status as single or members of a family.
Comprehensive Major Medical
A plan of insurance which has a low deductible, high maximum benefits, and a coinsurance feature. It is a combination of basic coverage and major medical coverage which has virtually replaced separate hospital, surgical and medical policies with each having its own deductible requirements. Also see Major Medical Insurance.
Concurrent Review
A case management technique which allows insurers to monitor an insured's hospital stay and to know in advance if there are any changes in the expected period of confinement and the planned release date.
Conditional Binding Receipt
This is the more exact terminology for what is often called a binding receipt. It provides that if a premium accompanies an application, the coverage will be in force from the date of application or medical examination, if any, whichever is later, provided the insurer would have issued the coverage on the basis of the facts revealed on the application, medical examination and other usual sources of underwriting information. A Life and Health Insurance policy without a conditional binding receipt is not effective until it is delivered to the insured and the premium is paid.
Conditionally Renewable
A contract that provides that the insured may renew it to a stated date or an advanced age, subject to the right of the insurer to decline renewal only under conditions stated in the contract.
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986
Legislation providing for a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued for up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may be continued for up to 36 months in nearly all other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.
Continuation
Allows terminated employees to continue their group health insurance coverage under certain conditions.
Contract Year
This period runs from the effective date to the expiration date of the contract.
Coordination of Benefits (COB)
A group policy provision which helps determine the primary carrier in situations where an insured is covered by more than one policy. This provision prevents an insured from receiving claims overpayments.
Copay (copayment)
This is an arrangement where the covered person pays a specified amount for various services and the health care provider pays the remainder. The covered person usually must pay his or her share when the service is rendered. Similar to coinsurance, except that coinsurance is usually a percentage of certain charges where the co-payment is a dollar amount.
Copay Provision
Often used with major medical policies. The copay provision states what percentage of a claim the company will pay and what percentage the insured will pay. For example, an 80 percent copay provision would provide that the insurer pay 80 percent of claims and the insured pay 20 percent.
Corridor Deductible
A Major Medical deductible that provides for a deductible, or "corridor," after the full payment of basic hospital and medical expenses up to a stated amount. In the event of further expenses, payment is on the basis of participation or coinsurance, such as 80%-20% or 85%-15%, and the deductible is that portion paid by the insured.
Cosmetic Procedures
Procedures which improve the appearance, but are not medically necessary.
Cost Contract
An agreement between a provider and the Health Care Financing Administration to provide health services to covered persons based on reasonable costs for service.
Cost of Living Benefit
An optional disability benefit where the monthly benefit will be increased annually once the insured is on claim for 12 months.
Cost Sharing
A situation where covered persons pay a portion of the health costs such as deductibles, coinsurance, or copayment amounts.
Covered Expenses
Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.
Covered Person
A person who pays premiums into the contract for the benefits provided and who also meets eligibility requirements.
Credentialing
This involves approving a provider based on certain criteria to provide or participate in a health plan.
Custodial Care
Care that is primarily for meeting personal needs such as help in bathing, dressing, eating or taking medicine. It can be provided by someone without professional medical skills or training but must be according to doctor's orders.
D