Health Insurance Glossary (A-E)

 Source:  Healthinsurance.org

Actuary

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.

Admitting privilege

Admitting privilege is the right granted to a doctor to admit patients to a particular hospital.

Advance care planning consultations

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

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

Any activity done to help a person or group to get something the person or group needs or wants.

Affordable care act (aca)

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 that will lower health care costs and improve system efficiency, and to eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions.

Agent

Licensed salespersons who represent one or more health insurance companies and presents their products to consumers.

Association

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.

Beneficiary

The beneficiary is enrolled in a health insurance plan and receives benefits through those policies.

Benefit

Benefit refers to the amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.

Brand-name drug

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

Licensed insurance salesperson who obtains quotes and plan from multiple sources information for clients.

Bronze plan

A Bronze health plan – available through state health insurance exchanges created by the ACA – covers 60 percent of the cost of essential benefits, while the patient pays 40 percent – up to an out-of-pocket maximum of roughly $6,000 for an individual or $12,000 for a family.

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 provider.

Carrier

The insurance company or HMO offering a health plan.

Case management

Case management is a system embraced by employers and insurance companies to ensure that individuals receive appropriate, reasonable health care services.

Certificate of insurance

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

A claim is 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.

Claim

A claim is an application for benefits provided by your health plan. You must file a claim before funds will be reimbursed to your medical provider. A claim may be denied based on the carrier’s assessment of the circumstance.

COBRA

COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985, federal legislation that allows you – if you work for an insured employer group of 20 or more employees – to continue to purchase health insurance for up to 18 months if you lose your job, or your employer-sponsored coverage is otherwise terminated.

Related terms: employer-sponsored health insurance

Coinsurance

Coinsurance refers to money that an individual is required to pay for services, after a deductible has been paid. In some health care plans, co-insurance is called “copayment.” Coinsurance 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.

Related terms: copayment, deductible

Consumer Operated and Oriented Plan (CO-OP)

The Affordable Care Act (ACA)  provides $6 billion in loans and grants to develop non-profit organizations that are run by their customers and meant to offer consumer-friendly, affordable health insurance options to individuals and small businesses. Plans, sold inside and outside the health insurance exchanges, will have to meet ACA standards for health plans.

CO-OPs are neither government agencies nor commercial insurers, and as such, were designed to put patients first, without worrying about investors or Congressional politics. The idea behind a CO-OP is that customers’ health insurance needs and concerns become a top priority because the CO-OP’s customer/members elect their own board of directors. What’s more, a majority of these directors must themselves be the CO-OP’s customers.

Profits made by the organization must be used to lower premiums, improve benefits, or sustain programs intended to enhance the quality of health care delivered to the CO-OP’s members.

Read more about Consumer Operated and Oriented Plans.

Cooperatives

Cooperatives or insurance cooperatives were proposed in the Senate as an alternative to a proposed government plan or public option. The cooperatives, which would have been structured as non-profits and owned by their members, would offer a network of health care providers or contract out for medical services. The concept championed by some Democrats would provide “seed money” for the cooperatives, which would then be sustained by customer premiums. Read this Commonwealth Fund history of health cooperatives

Copayment

Copayment 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 copayment for each office visit, regardless of the type or level of services provided during the visit. Copayments are not usually specified by percentages.

Related terms: co-insurance, deductible

Credit for coverage

 

Credit for coverage may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer’s (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines.

Deductible

The deductible is 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.

Related terms: coinsurance, copayment

Denial of claim

Denial of claim is the refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.

Dependent

A dependent is a person or persons relying on the policy holder for support may include the spouse and/or unmarried children (whether natural, adopted or step) of an insured.

Dependent worker

A worker in a family in which someone else has greater personal income.

Effective date

The effective date is the date your insurance coverage commences.

Electronic health record

An electronic health record is a long-term aggregate of a patient’s health information and may be a record of a variety of providers and types of medical care. This record is sometimes confused with an electronic medical record, which is a record of a patient’s health maintained by a physician as a record primarily of the physician’s care of the patient.

Electronic medical record

An electronic medical record is a record of patient health maintained by the patient’s physician as a record of that physician’s care of the patient. This record is often confused with an electronic health record, which is a more comprehensive, long-term aggregate of a patient’s health information and may be a record of a variety of providers and types of medical care.

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.

Employer mandate

The new health reform legislation requires employers with 50 or more employees to provide health coverage to those employees and sets a minimum baseline of coverage and employer contributions. Employers who do not comply will face annual penalties based on the number of employees in the firm.

Employer tax credits

Employer tax credits – or Small Business Health Care Tax Credits – provide a tax credit of up to 35 percent of small business premium costs in 2010 – with that rate increasing to 50 percent in 2014. Who’s eligible? Employers with fewer than 25 full-time workers and average annual wages less than $50,000. Read more about the credit.

Employer-sponsored health insurance

Of Americans who have health coverage, nearly 60 percent secure that coverage through an employer-sponsored plan, often called group health insurance. Millions take advantage of the coverage for reasons as obvious as employer responsibility for a significant portion of the health care expenses. Group health plans are also guaranteed issue, meaning that a carrier must cover all applicants whose employment qualifies them for coverage. In addition, employer-sponsored plans typically are able to include a range of plan options from HMO and PPO plan to additional coverage such as dental, life, short- and long-term disability. Read more about group health insurance. Read recent news articles about employer-sponsored health insurance.

Related terms: group health insurance, private health insurance, individual health insurance

Employer-sponsored health plans

Employer-sponsored health plans currently provide some level of health coverage for approximately 160 million Americans. Employer-sponsored health plans are more likely to be provided by larger companies; in fact, an estimated 99 percent of companies with 200 or more workers offer health benefits, according to recent testimony in Congress. However, the plans face rapidly escalating premiums – up 119 percent since 1998 – and even at larger firms, up to 21 percent of workers may not be eligible for coverge, even it it’s offered. Health reform legislation proposals in Congress may include an employer mandate, designed to increase participation by employers and by more of their employees.

Essential health benefits

Beginning in 2014, under the Affordable Care Act, all health insurance policies sold in state health insurance exchanges must cover what physicians and consumer advocates call essential health benefits. The benefits will ensure that 8.7 million Americans will gain maternity coverage, 4.8 million Americans will gain substance abuse coverage, 2.3 million Americans will gain mental health coverage, and 1.3 million Americans will gain prescription drug coverage.

Exchange

A health insurance exchange mechanism is a key provision of the Affordable Care Act, established to provide a selection of competing providers, each offering different qualified plans. All qualified plans must meet standards established and enforced by the Health Choices Administration. For instance, participating plans will not be allowed to discriminate against applicants based on health history (pre-existing conditions) or future risk. Competition between the plan providers would, in theory, encourage the providers to improve the quality and pricing of offered plans.

Exclusion

An exclusion is a provision within a health insurance policy that eliminates coverage for certain acts, property, types of damage or locations.

Explanation of benefits (EOB)

An explanation of benefits is the insurance company’s written explanation regarding a claim, showing what they paid and what the client must pay. The document is sometimes accompanied by a benefits check.

 

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