| |
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 employeed 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.
|