Health Insurance Terminology
Annual Out-of-Pocket Maximum
A dollar amount set by the plan which puts a cap on the amount of money the insured must pay out of his or her own pocket for covered expenses over the course of a calendar year.
Financial reimbursement and other services provided to insured individuals by insurers under the terms of an insurance contract. An example would be the benefits listed under a Life or Health Insurance policy or benefits as prescribed by a Workers Compensation law.
A request for payment under the terms of an insurance policy.
A specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the policy's deductible has been met.
Allows terminated employees to continue their group health insurance coverage under certain conditions.
Coordination of Benefits
A situation where identical or overlapping coverage exists between two or more insurance companies or service organizations.
This is an arrangement where the covered person pays a specified amount for various services and the health care provider pays the remainder. The covered person usually must pay his or her share when the service is rendered. Similar to coinsurance, except that coinsurance is usually a percentage of certain charges where the co-payment is a dollar amount.
Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.
A flat amount of covered medical expenses that an insured must incur before the insurer will make any benefit payments under a medical expense policy.
A person for whom the insured has some legal obligation. For most plans, it is the insured's spouse and/or children. Some plans also allow non-traditional spousal relationships (significant other, life-partner, etc.) to be considered a dependent with some additional certifying paperwork.
The process of identifying a disease.
A schedule of prescription drugs approved for use, which will be covered by the plan and dispensed through participating pharmacies.
The amount of time a student has to confirm or waive enrollment in an annual student health insurance plan.
Explanation of Benefits (EOB)
The abbreviation for Explanation of Benefits form that the insured receives from Aetna Student Health once a claim has been processed. The Explanation of Benefits form sets out exactly how the claim was paid and to whom.
When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name, but once its patent expires, other companies can sell the same drug under its chemical, or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the Food and Drug Administration requires generic drug manufacturers to show that a generic drug "delivers the same amount of active ingredient in the same time frame as the original product."
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Under this federal law (known as HIPAA), group health plans cannot deny coverage based solely on an individual's health status. This law also gives employees who cannot change or lose their jobs better access to health coverage, guarantees renewability and availability to certain employees and limits exclusions for pre-existing conditions. For example, under this law, group health plans must credit any employee the amount of time that they spent on any health plan prior to the new plan, which is known as "prior credible coverage." A pre-existing condition will be covered without a waiting period when an employee joins a new group plan if the employee has been insured for the previous 12 months with credible health insurance, with no lapse in coverage of 63 days or more. This means that if an employee has been insured for 12 months or more, the employee will be able to go from one job to another and his or her pre-existing coverage will remain intact -- without additional waiting periods. However, if an employee has a pre-existing condition and was not covered previously for 12 months before joining a new plan, the longest the employee will have to wait for their pre-existing coverage to be covered is 12 months.
Health Maintenance Organization (HMO)
An HMO is a prepaid medical service plan that provides services to plan members. Medical providers contract with the HMO to provide medical services to plan members. Members must use contracted providers. The emphasis is on preventative medicine.
A card given to each person covered under the plan, which identifies him or her as being eligible for benefits.
A patient admitted to a hospital or other similar medical facility as a resident patient.
The maximum amount of money a plan will pay towards healthcare services over the course of the insured's lifetime.
A system of health care where the goal is a system that delivers quality, cost-effective health care through monitoring and recommending utilization of services, and cost of services.
Managed Health Care Plan
A plan that involves financing, managing, and delivery of health care services. Typically, it involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost effective, but quality, service.
Maximum Out-of-Pocket Costs
The most a member will pay in any given year, considering co-payments, coinsurance, deductibles, etc.
A group of doctors, hospitals, and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.
Non-Preferred Provider (Out of Network Provider)
A provider who has not signed a contract with a health plan.
Services provided in the physician's office.
Health care services received outside the HMO, POS or PPO network.
Any medical care costs not covered by insurance, which must be paid by the insured.
A patient who is not a bed patient in the hospital in which he or she is receiving treatment.
Over-the-Counter Drugs (OTC)
A drug that can be purchased without a prescription.
A physical condition that existed prior to the effective date of a policy. In some health policies, these are not covered until after a stated period of time has elapsed.
Preferred Provider (In-Network Provider)
A provider who has signed a contract with a health plan.
A specified amount of money that the insurer receives in exchange for its promise to provide health insurance to an individual or a group.
This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur.
Basic health care provided by doctors who are in the practice of family care, pediatrics, and internal medicine.
A cost containment measure that provides full payment of health benefits only when the hospitalization or medical treatment has been approved in advance.
Reasonable and Customary Charges
The charge for medical services which refers to the amount approved by the Medicare Carrier for payment. Customary charges are those which are most often made by a provider for services rendered in that particular area.
Occurs when a physician or other health plan provider receives permission to consult another physician or hospital.
A method of ranking sick or injured people according to the severity of their sickness or injury in order to ensure that medical and nursing staff facilities are used most efficiently.
The process of selecting risks and classifying them according to their degrees of insurability so that the appropriate rates may be assigned. The process also includes rejection of those risks that do not qualify.
Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached the level of extreme emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.
Usual, Customary and Reasonable fee
The maximum dollar amount of a covered expense that is considered eligible for reimbursement under a major medical policy.