|
|
|
HEALTH INSURANCE GLOSSARY
|
Business New Haven
6/14/99
By: BNH
|
Benefits: Services covered under health plan. Amount paid is determined by plan design and reasonable and customary charges.
Carrier: Insurance company.
Care Management: A process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs. Medical care providers and the insurance company coordinate resources to promote quality and cost-effective outcomes.
COBRA: Premiums paid after termination of employment, divorce or death, to the employer or carrier for the continuation of benefits for a time period determined by law.
Coinsurance: A cost shared between the insurance company and the health plan member, by which a member must pay a certain percentage of covered costs, usually after first paying a deductible.
Copayment: Also called "co-pay". A fixed (according to the contract) amount a covered person pays for care, usually at the time care is given.
Deductible: The amount a health plan member is responsible for before the carrier begins to reimburse for medical benefits (not all plans have deductibles). Deductibles may apply to certain hospital and or doctor's visits.
EOB (Explanation of Benefits): When the member's claim has been processed by the carrier, the EOB breaks down the way the money has been distributed.
Gatekeeper: A physician, typically called a Primary Care Physician (PCP) who functions as the member's first contact for the delivery of care. The gatekeeper may refer the member to a specialist (generally referred to as a referral).
Health Maintenance Organization: A licensed organization that provides both health care coverage and coordinates delivery of care.
Hospice: A facility, organization or agency, certified by Medicare, that is primarily engaged in providing pain relief, symptom management and supportive services to terminally ill people and their families.
Indemnity Plan: A plan which gives a member the choice of using any doctor. The plan is subject to a deductible and coinsurance (usually 80/20 percent) until out-of-pocket responsibility has been satisfied. Claims need to be filed in most instances.
Late Entrant: An eligible employee and/or dependent who requests health insurance following the open-enrollment effective date, if applicable, or more than 31 days after the employee's and/or dependent's wait period requirement has been met. Eligibility for coverage will be determined according to the individual health insurance plan sponsored by the employer group.
An eligible employee and/or dependent shall not be considered a late enrollee if a request for membership is made and one of the following conditions satisfied:
A) Coverage was not elected when the employee and/or dependent was first eligible under the benefit program solely because another group health insurance plan provided coverage for the eligible employee and/or dependent and coverage is lost under that plan due to employment termination, death of a spouse, divorce or due to that plan's involuntary termination or cancellation by its carrier, for reasons other than non-payment of premium, and the employee and/or dependent enrolls under the benefit program within 31 days after the loss of membership under the other plan; or
B) The eligible employee and/or dependent is employed by an employer which offers multiple health program options and the employee and/or dependent elects a different program option during an enrollment period; or
C) The request for enrollment is made 31 days after:
o the marriage of the member; or
o the birth, or adoption of a child by the member; or
o issuance of a court order of legal guardianship or qualified child support.
Lifetime Maximum: The highest dollar amount a health plan will pay during a member's lifetime (usually $1,000,000 to unlimited).
Medical Emergency: The onset of a serious illness or injury that requires emergency medical treatment; or the onset of symptoms of sufficient severity that a member reasonably believes that emergency medical treatment is needed.
Medicare: A national health insurance program to which all Social Security recipients who are either over 65 years of age or permanently disabled are entitled. In addition, individuals receiving railroad retirement benefits and individuals suffering from end-stage renal disease are eligible to receive Medicare benefits.
Medicare is not a welfare program, and should not be confused with Medicaid. The income and assets of a Medicare beneficiary are not a consideration in determining eligibility or benefit payments. Medicare is a national program and procedures should not vary significantly from state to state.
Coverage under Medicare is similar to that provided by private insurance companies: it pays a portion of the cost of some medical care. Often deductibles and co-insurance (partial payment of initial and subsequent costs) are required of the beneficiary.
Medicare has two parts, A and B. Part A covers inpatient hospital care, hospice care, inpatient care in a skilled nursing facility and home health care services. Part B covers medical care and services provided by doctors and other medical practitioners, durable medical equipment and some outpatient care and home health-care services.
Medicare Managed Care (Medicare Risk): An increasing number of beneficiaries are receiving health services through managed-care plans. The Medicare managed-care benefit is different from the traditional Medicare "fee for services" system. Generally, a Medicare managed-care plan administers the health-care treatment of an enrollee by the use of a physician (known as a "gatekeeper") who must approve the patient's referral to specialized care. (Some Medicare managed plans permit beneficiaries to go directly to a specialized care provider, without the gatekeeper's approval, in return for payment of an extra premium.) A beneficiary may choose to receive Medicare coverage and care through a managed care plan by filing an enrollment form. Once the choice is made, a beneficiary generally must receive all of his or her care through the plan in order to receive Medicare coverage.
After a predetermined time the beneficiaries may choose to change to a different managed-care plan or return to the traditional Medicare plan.
Member: Plan participant or patient.
Network: A body of participating health-care providers that has agreed to provide care for the policy holder.
A) "In-network" denotes care delivered by a participating provider.
B) "Out-of-network" denotes care delivered by a non-participating provider.
Out-of-Pocket Maximum: The most a member will pay for covered services subject to deductible and coinsurance. After reaching this maximum, covered services are paid at 100 percent.
Participating Provider: Physician and most health-care providers.
Point-of-Service Plan: An indemnity option available under a managed-care plan; entails deductible and co-insurance and generally pays at a lower level than the traditional indemnity plan (ex: 70/30 percent).
Precertification: A process requiring prior approval for care given (not all services require precertification).
Premium: Payment made for health-insurance coverage by insured party.
Preventive Care: Care that focuses on wellness and keeping the member healthy.
Primary Care Physician: Your chosen doctor who coordinates your care.
Primary and Secondary Insurance: When a member is insured by more than one company. A determination will be made as to who the primary carrier is. That carrier will pay benefits first. There will be no duplication of payment on claims.
Reasonable & Customary: Maximum allowable amount paid by an insurance company based on its data.
Referral: A recommendation from a Primary Care Physician (PCP) for a member to receive care from another provider, usually in writing or by telephone, depending on contract.
Self-Referral: When the member's health plan authorizes him/her to see a doctor or specialist without a referral.
Urgent Care: Care for an illness or injury that is not a medical emergency but requires immediate medical attention.
Wait Period: Period of time before a full-time employee (one who works 30 or more hours weekly) becomes eligible for medical benefits. Period of time determined by employer policy.
|
Go FirstGo PreviousGo
NextGo LastGo
to Index
|
|
