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A
Admitting Privileges: The right granted to a doctor
to admit patients to a particular hospital.
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
individual health insurance plans specially designed for their
members.
B
Benefit: Amount payable by the insurance company
to a claimant, assignee, or beneficiary when the insured suffers
a loss.
C
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 charges 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.
D
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.
E
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.
H
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 (HMOs): Health
Maintenance Organizations represent "pre-paid" or
"capitated" insurance plans 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.)
I
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.
L
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.
M
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.
O
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.
P
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.
R
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.
S
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.
T
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.
U
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.
W
Waiting Period: A period of time when you are not
covered by insurance for a particular problem.
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