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 needs or wants.
Association: A group.
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 pay to a health maintenance organization (HMO), regardless of how much you use (or don't use) the services offered.
Case Management: Case management is a system embraced by insurance companies to ensure that individuals receive appropriate, reasonable health care services.
Claim: A request by an individual (or his or her provider) to the insurance company to pay for services obtained from a health care professional.
Co-Insurance: Refers to money that an individual is required to pay for services, after a deductible has been paid. Co-insurance is specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the insurance company pays 80 percent.
Co-Payment: Co-payment is a predetermined (flat) fee that an individual pays for certain health care services. For example, 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 covers the costs. Often, insurance plans are based on yearly deductible amounts.
Denial Of Claim: Refusal by an insurance company to honor a request to pay for health care services.
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 Maintenance Organizations (HMOs): 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 employed by, or under contract with, the HMO. HMO's vary in design. Depending on the type of HMO, services may be provided in a central facility, or in a physician's own office.
Indemnity Health Plan: Indemnity health insurance plans are also called "fee-for-service." These types of plans primarily existed before the rise of HMOs 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. Indemnity health plans offer individuals the freedom to choose their health care professionals.
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.
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 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.
Out-Of-Network: This phrase usually refers to physicians, hospitals or other health care providers who are nonparticipants in an insurance plan (usually an HMO or PPO). Depending on the health insurance plan, services provided by out-of-network health professionals may not be covered, or covered only in part.
Out-Of-Pocket Maximum: A predetermined, limited amount of money that an individual must pay, before an insurance company will pay 100 percent for an individual's health care expenses.
Outpatient: A 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.
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.
Pre-Admission 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 may be excluded from coverage by an insurance company, because the condition was believed to exist prior to obtaining a policy from the particular insurance company. Pre-existing conditions can be covered under many circumstances.
Preferred Provider Organizations (PPOs): You receive discounted rates if you use doctors from the network. If you use a physician outside the network 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 "gatekeeper" for an individual's medical care, referring the individual to more specialized physicians for specialist care.
Provider: 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: Employer sponsored 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.
