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ACCREDITED (ACCREDITATION)  look up translate image
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  look up translate image
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.
ACTUARY  look up translate image
An actuary is a health insurance carrier number cruncher responsible for determining what premiums the company needs to charge based in large part on claims paid versus amounts of premium generated. Their job is to make sure a block of business is priced to be profitable.
ADMINISTRATIVE SERVICES ONLY (ASO)  look up translate image
An arrangement in which an employer hires a third party to deliver employee benefit administrative services to the employer. These services typically include health claims processing and billing. The employer bears the risk for health care expenses under an ASO plan.
ADMITTING PHYSICIAN  look up translate image
The doctor responsible for admitting you to a hospital or other inpatient health facility.
ADMITTING PRIVILEGE  look up translate image
Admitting privilege is the right granted to a doctor to admit patients to a particular hospital.
ADMITTING PRIVILEGES  look up translate image
The right granted to a doctor to admit patients to a particular hospital
ADVANCE CARE PLANNING CONSULTATIONS  look up translate image
A controversial provision of H.R. 3200 would have paid physicians to provide counseling to elderly or terminally ill patients who request the counseling. The provision ultimately omitted from the passed health reform legislation would have paid for one counseling session at least every five years, during which patients could discuss advance care planning, advance directives, living wills, palliative care and hospice and possible life-sustaining treatments for the terminally ill. Critics said the proposal would create "death panels" and described its intent as "guiding you in how to die."
ADVANCE DIRECTIVE  look up translate image
An advance directive indicates the person designated to make medical decisions for you if you are unable physically or mentally to make those decisions yourself.
ADVOCACY  look up translate image
Any activity done to help a person or group to get something the person or group needs or wants.
AFFORDABLE CARE ACT (ACA)  look up translate image
The Patient Protection and Affordable Care Act (PPACA) also known as the Affordable Care Act or ACA is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation includes a long list of health-related provisions that began taking effect in 2010 and will "continue to be rolled out over the next four years." Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures...(more)
AFTER CARE  look up translate image
The care or follow-up treatment needed by a patient who has recently undergone surgery, been involved in an accident or has experienced an illness requiring hospitalization.
AGENT  look up translate image
Licensed salespersons who represent one or more health insurance companies and presents their products to consumers.
AGENT OF RECORD  look up translate image
The insurance agent recognized by a client to represent the client's interests in doing business with an insurance company.
ALLOWABLE CHARGE  look up translate image
The amount a benefit plan determines to be a reasonable charge for a service.
AMBULATORY CARE  look up translate image
All types of health services that do not require an overnight hospital stay
AMBULATORY SURGERY  look up translate image
Surgery performed on an outpatient basis where the patient is goes home the same day of the surgery.
ANCILLARY SERVICES  look up translate image
Services, other than those provided by a physician or hospital, which are related to a patient's care, such as laboratory work, x-rays and anesthesia
ANY WILLING PROVIDER LAWS  look up translate image
Legislation that requires health care plans to accept into their PPO and HMO networks any provider willing to agree to the network's terms and conditions
APPEAL  look up translate image
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.
ASSIGNMENT OF BENEFITS  look up translate image
When an insured person assign benefits, they sign a document allowing the hospital or doctor to collect health insurance benefits directly from the health insurance company. Otherwise, the insured person pays for the treatment and is later reimbursed by the health insurance company.
ASSOCIATION  look up translate image
Associations can offer group health insurance plans specially designed for their members and that give their members purchasing power because of the groups larger pool of enrollees.
ATTACHMENT  look up translate image
A policy modification which changes, restricts or clarifies coverage
BENEFICIARY  look up translate image
A person eligible for benefit under a health insurance policy
BENEFIT  look up translate image
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss
BENEFIT CAP  look up translate image
Total dollar amount that a payer will reimburse for covered health care services during a specified period, such as one year
BENEFIT PACKAGE  look up translate image
The list of covered services a benefit plan offers to a group or individual.
BENEFITS  look up translate image
The payments or value of services available under the coverage of a plan for treatment of medical costs.
BOARD CERTIFIED  look up translate image
A physician who has passed examinations given by a medical specialty group and who has, as a result, been certified as a specialist in this area of practice
BRAND-NAME DRUG  look up translate image
Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.
BROKER  look up translate image
A licensed legal representative of the policyholder, who negotiates with an insurance company on behalf of a customer, but is paid a commission by the insurance company.
CAPITATION  look up translate image
Capitation represents a fixed monthly dollar amount that a Health Maintenance Organization (HMO) pays to a group of health care providers who have contracted with the HMO. The amount of this fixed dollar amount depends upon the number of HMO enrollees who have chosen this group of health care providers for "primary care" services under the HMO plan. This fixed dollar amount does not vary with how much HMO enrollees use (or don't use) services offered by this group of HMO providers. Not all HMO utilize capitation payments.
CARE PLAN  look up translate image
A written plan for one's health care
CARRIER  look up translate image
The insurance company or HMO offering a health plan.
CASE MANAGEMENT  look up translate image
Comprehensive coordination or supervision of a member's healthcare when the chronically ill or otherwise impaired person may require long-term care.
CASE MANAGEMENT:  look up translate image
A process whereby an insured person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner
CASE MANAGER  look up translate image
A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.
CATASTROPHIC ILLNESS  look up translate image
A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.
CENTERS OF EXCELLENCE  look up translate image
Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants
CERTIFICATE OF COVERAGE:  look up translate image
A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company
CERTIFICATE OF INSURANCE  look up translate image
The certificate of insurance is a printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. It discloses what is covered, what is not, and dollar limits.
CLAIM  look up translate image
Form submitted to a payer (by a health care provider or patient) to request payment for items or services
CLINICAL PRACTICE GUIDELINES  look up translate image
Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it
CO-INSURANCE  look up translate image
Cost-sharing arrangement between an insured person and the health insurance company in which the insured person is required to pay a percentage of the cost for the health care services received. Coinsurance typically applies after satisfaction of a deductible. For example, 80% coinsurance may apply after a $500 deductible has been satisfied.
CO-PAYMENT (CO-PAY)  look up translate image
Co-payment is a predetermined fee, in addition to what health insurance covers, that an individual pays for health care services. For example, a PPO may require a $20 "co-payment" for normal services delivered during a physician office visit.
COBRA  look up translate image
Consolidated Omnibus Budget Reconciliation Act. A federal law passed in 1985 that permits many people who lose eligibility under a group health plan to continue using that coverage.
COINSURANCE  look up translate image
The percentage of costs a patient pays out-of-pocket for medical care.
COINSURANCE MAXIMUM  look up translate image
The total amount of coinsurance a member pays each year before the benefit plan pays 100% of allowable charges for covered services.
CONCURRENT REVIEW  look up translate image
Concurrent review involves monitoring the medical treatment and progress toward recovery, once a patient is admitted to a hospital, to assure timely delivery of services and to confirm the necessity of continued inpatient care. This monitoring is under the direction of medical professionals. Concurrent review is a component of "Utilization Review."
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)  look up translate image
The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for employees and their dependents for 18 months after the employee leaves the job. Longer durations of continuance are available under certain circumstances. If a former employee opts to continue coverage under COBRA, the former employee must pay the entire premium, plus a 2% administration charge.
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Health insurance terms
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Created by admin
Created on 2011-05-19 08:12:22
Number of terms 273
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Sources
  • Glossary of Common Healthcare Benefit Terms
    www.healthsmart.com
  • Health insurance glossary
    www.healthinsurance.org
    A consumer dictionary of terms used in the health insurance industry.
  • Healthcare Coverage Glossary
    www.bcbs.com
    Glossary of healthcare coverage terms