GLOSSARY OF TERMS
- index
A |
B |
C |
D |
E |
H |
I |
L |
M |
O |
P |
R |
S |
T |
U |
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. 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, $20 or more "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.
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
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
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 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.
•
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.
•
Out-Of-Pocket Maximum:
A predetermined limited amount of money that
an individual must pay out of their own savings,
before an insurance company 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.
P •
Pre-Admission Certification:
Also called pre-certification review, or pre-admission
review. Approval by a case manager or insurance
company representative 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
network. 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.
