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Actuary - a mathematician in the insurance field. Responsible for
calculating premiums, developing plans and defining underwriting risk. Agent -
a licensed individual who represents several insurance companies and
sells their products. Benefit - reimbursement for covered medical expenses as specified by the
plan. Brand-Name Drug - prescription drug which is marketed with a specific brand name
by the company that manufactures it. May cost insured individuals a
higher co-pay than generic drugs on some health plans. (see
"generic.") Broker - a licensed insurance professional who obtains multiple quotes
and plan information in the interest of his client. Carrier -
insurance company or HMO insuring the health plan. Certificate Booklet - the plan agreement. A printed description of the benefits and
coverage provisions intended to explain the contractual arrangement
between the carrier and the insured group or individual. May also be
referred to as a policy booklet Claim - a
formal request made by an insured person for the benefits provided by a
policy. COBRA (Consolidated Omnibus Budget Reconciliation Act) -
Federal legislation that requires group health plans to provide health
plan members the opportunity to purchase continued coverage in the event
their insurance is terminated. Applies only to employer groups with 20
or more employees. Learn more about COBRA at the Department of
Labor's website. - Please note this may take a few minutes to appear. Co-Insurance - the percentage of covered expenses an insured individual shares
with the carrier. (i.e., for an 80/20 plan, the health plan member's
co-insurance is 20%.) If applicable, co-insurance applies after the
insured pays the deductible and is only required up to the plan's stop
loss amount. (see "stop loss.") Co-Pay/Co-Payment - the amount an insured individual must pay toward the cost
of a particular benefit. For example, a plan might require a $10 co-pay
for each doctor's office visit. Credit for Prior Coverage - any pre-existing condition waiting period met under an
employer's prior (qualifying) coverage will be credited to the current
plan, if any interruption of coverage between the new and prior plans
meets state guidelines. Deductible - the dollar amount an insured individual must pay for covered
expenses during a calendar year before the plan begins paying
co-insurance benefits. Dependents - usually the spouse and unmarried children (adopted, step or
natural) of an employee. Effective Date - the date requested by an employer for insurance coverage to
begin. Exclusions - expenses which are not covered under an insurance plan.
These are listed in the Certificate Booklet. Explanation of Benefits (EOB) - a carrier's written response to a claim for benefits. Sometimes
accompanied by a benefits check. Generic Drug - the chemical equivalent to a "brand name drug."
These drugs cost less, and the savings is passed onto health plan
members in the form of a lower co-pay. Group Insurance - an insurance contract made with an employer or other entity
that covers individuals in the group. Health Maintenance Organization (HMO) - An alternative to commercial insurance that stresses
preventive care, early diagnosis and treatment on an outpatient basis.
HMOs are licensed by the state to provide care for enrollees by
contracting with specific health care providers to provide specified
benefits. Many HMOs require enrollees to see a particular primary care
physician (PCP) who will refer them to a specialist if deemed necessary. HIPAA -
Health Insurance Portability and Accountability Act of 1996, P.L.
104-91. This law relates to underwriting, pre-existing limitations,
guaranteed renewal, COBRA and certification requirements in the event
someone terminates from the plan. The new law, commonly known as the
"Kennedy-Kassebaum Bill," establishes new requirements for
self-funded, fully-insured group plans (including church plans) and
Individual Health policies. The purpose of the law is to:
Pre-Certification - an insurance company requirement that an insured obtain
pre-approval before being admitted to a hospital or receiving certain
kinds of treatment. ID Card/Identification Card - card given to insured individuals which advises medical
providers that a patient is covered by a particular health insurance
plan. Indemnity Insurance Plans - traditional insurance plans (not HMOs or PPOs) which permit
insured individuals to choose their doctors and hospitals. Insured
individuals do not have to choose doctors or hospitals from a specific
list of providers. Also called "fee-for-service" plans. In-Network - describes a provider or health care facility which is part of a
health plan's network. When applicable, insured individuals usually pay
less when using an in-network provider. Lifetime Maximum Benefit - the maximum amount a health plan will pay in benefits to an
insured individual. Limitations - a restriction on the amount of benefits paid out for a particular
covered expense. Long-Term Disability (LTD) - insurance which pays employees a percentage of monthly earnings
in the event of disability. Managed Care - the coordination of health care services in the attempt to
produce high quality health care for the lowest possible cost. Examples
are the use of primary care physicians as gatekeepers in HMO plans and
pre-certification of care. Multiple Employer Trust (MET) - an arrangement created to obtain health and other benefits
for participating employer groups. Small employers can pool their
contributions to receive the advantages of large group underwriting. Network - a group of doctors, hospitals and other providers contracted to
provide services to insured individuals for less than their usual fees.
Provider networks can cover large geographic markets and/or a wide range
of health care services. If a health plan uses a preferred provider
network, insured individuals typically pay less for using a network
provider. Out-of-Network - describes a provider or health care facility which is not part of
a health plan's network. Insured individuals usually pay more when using
an out-of-network provider, if the plan uses a network. Out-of-Pocket Maximum - the total of an insured individual's co-insurance payments and
co-payments. Plan Administration - overseeing the details and routine activities of installing and
running a health plan, such as answering questions, enrolling new
individuals for coverage, billing and collecting premiums, etc. Point-of-Service (POS) - health plan which allows the enrollee to choose HMO, PPO or
indemnity coverage at the point of service (time the services are
received). Pre-Certification - Pre-admission review and approval of appropriateness and
medical necessity of hospitalization or other medical treatment. Pre-Existing Condition - an illness, injury or condition for which the insured
individual received medical advice, treatment, services or supplies; had
diagnostic tests done or recommended; had medicines prescribed or
recommended; or had symptoms of typically within 12 months (time periods
may vary depending on state laws) prior to the effective date of
insurance coverage. Preferred Provider Organization (PPO) - A network or panel of physicians and hospitals that agrees to
discount its normal fees in exchange for a high volume of patients. The
insured individual can choose from among the physicians on the panel. Premiums - payments
to an insurance company providing coverage. Provider - any person or entity providing health care services, including
hospitals, physicians, home health agencies and nursing homes. Usually
licensed by the state. Referral - within many managed care plans, transfer to specialty physician
or specialty care by a primary care physician. Rider - a
modification to a Certificate of Insurance regarding clauses and
provisions of a policy. A rider usually adds or excludes coverage. Risk - uncertainty
of financial loss. Short-term Medical - temporary health coverage for an individual for a short
period of time, usually from 30 days to six months. Small Employer Group - groups with 1  99 employees. The definition
of small employer group may vary between states. State Mandated Benefits - state laws requiring that commercial health insurance plans
include specific benefits. Stop-Loss - the dollar amount of claims filed for eligible expenses at which
the insurance begins to pay at 100% per insured individual. Stop-loss is
reached when an insured individual has paid the deductible and reached
the out-of-pocket maximum amount of co-insurance. Third Party Administrator (TPA) - An organization responsible for marketing and administering small
group and individual health plans. This includes collecting premiums,
paying claims, providing administrative services and promoting products. Underwriter - entity that assumes responsibility for the risk, issues insurance
policies and receives premiums. Waiver of Coverage - a section on the enrollment form which states that an
employee was offered insurance coverage but opted to waive this
coverage. Worker's Compensation Insurance - insurance coverage for work-related illness and injury. All
states require employers to carry this insurance. |