Glossary of Health Insurance Terms
Accidental Death and Dismemberment:
Can either be sold as a policy by itself or can be included as a
provision of some policies. In the case of an accident, the
insurance company will pay either a lump sum or a weekly amount over
a specific period.
Acute Care:
Skilled, medically professional care given to a patient in order to
restore them to functional health.
Assisted Living Facility:
A residential community for senior citizens that also provides
nursing care.
Anthem Blue Cross Blue Shield:
One of the largest PPO providers of individual and group health
insurance in Colorado.
Annuity:
There are a wide variety of annuity products, including immediate and deferred; fixed-rate; equity-indexed; CD-type annuities; and IRA qualified annuity products.
For more information please visit Colorado Fixed Annuity
Brokers.
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Basic Medical
Insurance:
Insurance typically covering the hospital, surgical, and physician
expenses including hospital room and board, cost of x-rays,
anesthesia, operating room, additional lab charges, surgeon fees,
and routine doctor visits
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Case Manager:
A doctor or nurse affiliated with a managed care plan that arranges
and approves medical care for the insured.
Closed Panel: Also known as the gatekeeper system, this is
the procedure used by managed care plan in which the member's
primary care physician makes referrals to other network health care
providers.
COBRA:
Consolidated Omnibus Budget Reconciliation Act of 1986. Terminated
employees or those who lose coverage because of reduced work hours
may be able to buy group coverage for themselves and their families
for limited periods of time.
Coinsurance:
The amount you are required to pay for medical care in a
fee-for-service plan after you have met your deductible. The
coinsurance rate is usually expressed as a percentage and may have a
stop loss limit.
Copayment:
A charge you pay for medical services. Your health care plan covers
the remaining medical charges. As an example, you may pay $25 for an
office visit or a prescription.
Covered Expenses:
The medical procedures the insurer agrees to provide coverage. Most
insurance plans, whether they are fee-for-service, HMOs, or PPO, do
not pay for all services. All the services the insurance company
agrees to pay for will all be listed in the policy.
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Deductible:
The amount of money you must pay for medical care expenses before
your insurance policy starts reimbursing you. Most deductibles are
on a yearly basis but check your policy. A rule of the thumb
is the higher the deductible the lower the premium.
Dental Insurance Plans:
A type of policy designed to cover your dentist visits and
procedures that are often not covered by managed care health plans.
Discount Dental Plans:
Not really insurance, but rather "membership programs"
that offer discounts on dental procedures and dentist visits. A
cheaper alternative to Dental insurance.
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Elimination Period:
The period of time when no benefits are received during a stay in a
long-term care facility.
Elimination Rider:
A rider that eliminates a medical condition from being covered
permanently or for a specified period of time.
Exclusions:
Specific conditions or circumstances for which the policy will not
provide benefits.
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Formulary:
A type of prescription medicine classification.
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Gatekeeper Physician:
The primary care physician chosen by the insured. The physician is
responsible for referrals to specialists and for supervising the
medical care of the health plan member.
Group Health
Insurance:
Also known as "small business health insurance", this type
of coverage is available to small businesses with between 2 and 50
employees, as well as (at least in theory) any small club, group,
etc. It often offers less expensive premiums, tax advantages to
business owners, and in most cases, coverage cannot be denied.
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Health Care Financing Administration:
The administration that oversees Medicare and Medicaid and also sets
standards health care providers must meet in order to become
certified as a qualified Medicare provider.
Health Maintenance Organization (HMO):
Health plans that work with a network of hospitals and doctors to
provide a range of health services to their members. For a monthly
premium, the HMO may cover your doctor visits, hospital stays,
emergency care, surgery, checkups, lab tests, x-rays, and therapy.
You are required to use the doctors and hospitals designated by the
HMO.
Health
Savings Accounts ( HSA plans ):
Government-approved plans, designed to help people to save on
medical insurance by purchasing a high deductible managed
care plan, and saving for deductible expenses in a tax-advantaged
savings account.
High Deductible Insurance Plan:
A term used to describe major medical health insurance plans for
Health Savings Accounts. For 2004, a high deductible insurance plan is a health plan with a minimum deductible of
$1000 for self-only coverage and $2,000 for family coverage. The maximum out-of-pocket expenses for allowed costs must be no more than $5,000 for self-only coverage and no more than $10,000 for family.
HIPPA:
Health Insurance Portability and Accountability Act of 1996. It is
designed to protect health insurance coverage for workers and their
families when they change or lose their jobs.
Home Health Care:
Medical services administered at the patient's home such as nursing
care and speech, occupational or physical therapy.
Hospice Care:
Care given on a regular basis to terminally ill patients.
Hospital Indemnity Insurance:
This insurance offers limited coverage. It pays a fixed amount for
each day, up to a maximum number of days. You may use it for medical
or other expenses.
Indemnity Contracts:
Policies that provide a set amount per day during confinement in
a hospital or long-term facility.
Indemnity Insurance Plans:
Insurance plans that pay for medical services provided by any
hospital or doctor.
Intermediate Nursing Care:
Health care for individuals who need minimal supervision.
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Joint Commission on Accreditation of Health care Organizations
(JCAHO):
Responsible for the accreditation of health care organizations
after careful evaluation of the services provided to determine
quality care.
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Lifetime Maximum:
The maximum percentage of benefits available to a member during
their lifetime, in which, all benefits served are subject to this
limit unless stated as unlimited.
Long-Term Care:
Care for patients with chronic diseases or disabilities
including home health care, adult day care, hospice care, respite
care, and intermediate care but not hospital care.
Long-Term Care Insurance:
This type of insurance covers the costs of nursing home care,
which can be several thousand dollars each month. Long-term care is
usually not covered by health insurance except in a very limited
way.
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Major Medical
Insurance:
Insurance that covers the expenses related to hospitalization.
Provides a fixed amount of money to be used throughout the lifetime
of the insured.
Managed Care:
Health plans that control the cost, use and quality of the
health care system. These plans combine physicians, hospitals, and
insurance plans into a single network.
Maximum Out-of-Pocket:
The most money you will be required pay a year for deductibles
and/or coinsurance. It is a stated dollar amount set by the
insurance company, in addition to regular premiums. It limits the
amount you will have to pay in a given year for health care
services.
Medicaid:
The federal health insurance program for low-income Americans.
Medical Savings
Accounts ( MSA plans ):
Government-approved plans, designed to help the self-employed to
save on medical insurance by purchasing a high deductible
managed care plan, and saving for deductible expenses in a
tax-exempt savings account. MSA's were replaced by Health
Savings Accounts on January 1st, 2004.
Medicare:
The federal health insurance program for people 65 and older or
people who are totally disabled. Hospital Insurance (or Plan A)
under Medicare, which is available to seniors when they reach the
age of 65, covers in-patient hospital care, skilled nursing care,
home health care, and hospice care. Medical Insurance (or Plan B)
under Medicare, a voluntary program, covers physician service,
physical therapy, ambulance expenses, and out-patient services. You
are required to pay a premium for the services under Plan B.
Medicare Supplemental Insurance:
Also known as "Medigap". This type of coverage helps
seniors cover the costs of "gaps" in the coverage provided
by Medicare.
Medigap:
See "Medicare Supplemental Insurance" above.
Medical
Information Bureau or MIB:
When a consumer applies for life, health, disability, or
long-term care insurance coverage, the insurer may check for a record at MIB. The purpose of the
MIB report is to detect and deter
applicants from omitting or misrepresenting significant facts. The insurer who
receives a record from MIB will compare it with information provided by the
applicant. If the information in the MIB record is inconsistent with other
information, the insurer may conduct further investigation. Click
here to get a copy of your MIB record
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Non-cancelable Policy:
A policy that guarantees you can receive insurance, as long as
you pay the premium. It is also called a guaranteed renewable
policy.
Nursing Home Care:
Care an individual receives in a nursing home which includes
custodial and nursing services.
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Pre-existing Condition:
A health problem that existed before the date your insurance
became effective. Some insurance policies deny coverage for
pre-existing conditions entirely others do only for a set period of
time.
Preferred Provider Organization (PPO):
A network of providers that have agreed to provide services for
a discounted rate. When you use the doctors and hospitals that are
part of the established PPO network, a large part of your medical
bills are covered. You can use other doctors outside the network,
but at a higher cost.
Premium:
The amount you pay in exchange for insurance
coverage.
Preventative Care:
Services that focuses on prevention such as mammograms,
immunizations, shots, physical exams and diagnostic tests.
Primary Care Physician (PCP):
Usually your first contact for health care. This is often a
family physician or internist, but some women use their
gynecologist. A primary care physician monitors your health and
diagnoses and treats minor health problems, and refers you to
specialists if another level of care is needed.
Provider:
Any person (doctor, nurse, dentist) or institution (hospital or
clinic) that provides medical care.
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Rider:
An attachment to a policy explaining any changes, additions or
exclusions made to a standard insurance policy.
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Self-Employed Health
Insurance:
Insurance for the self-employed is often more expensive and more
limited, however, similarly to all "small business health
insurance", it offers certain tax advantages.
Short Term Health
Insurance:
A type of health insurance plan purchased to cover gaps in
coverage, which can occur between jobs, after a move, etc.
Small Business Health
Insurance:
Also known as "small group health insurance", this
type of coverage is available to small businesses with between 2 and
50 employees.
Stop-Loss Provision:
The point when the insurance company will begin to pay 100% of
accrued medical expenses up to a set maximum benefit amount.
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Temporary Health
Insurance:
A type of health insurance plan purchased to cover gaps in
coverage, which can occur between jobs, after a move, etc.
Third-Party Payer:
Any payer for health care services other than you. This can be
an insurance company, an HMO, a PPO, or the Federal Government, in
the case of Medicare or Medicaid coverage.
Travel Health
Insurance:
Coverage purchased to cover travelers abroad.
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Usual, Customary and Reasonable Charges:
The price for medical services the insurance company determines
to be the average charge for similar procedures in a given
geographical location.
This information is not your policy and is intended as a brief
and general overview of terminology. If there is any
difference between information on this page and your health
insurance policy, the provisions and definitions specified in the
policy shall control.
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