Health Insurance Glossary A-H
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Accidental Death and Dismemberment:
Can either be sold as a policy by itself or can be included as a provision of a policy. In the case of an accident, the insurance company will pay either a lump sum or a weekly amount over a specific period.
Based on a variety of quality standards the National Committee for Quality Assurance grants health plans three classes of accreditation: Full, One-Year, and Provisional.
Skilled, medically professional care given to a patient in order to restore them to functional health.
An individual covered under the plan that is not named as an insured in the policy's terms.
Assisted Living Facility:
A residential community for senior citizens that also provides nursing care.
Basic Medical Insurance:
Insurance covering the typical 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
A percentage of the standard premium that covers the initial administrative expenses the insurance company incurs while designing your policy.
The interval in which you are able to receive benefits. Typically, the benefit period begins with the first medical service received for an illness and ends after you have not been hospitalized due to the condition for 60 consecutive days.
After meeting certain requirements set by national boards, completing residency training, passing exams, and practicing for several years, physicians can become certified. To maintain certification the physician must continue to take medical classes throughout their careers.
A doctor or nurse affiliated with a managed care plan that arranges and approves medical care for the insured.
Fixed monthly fee paid to an insurance company in exchange for full care if an individual.
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.
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. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
A combination of Basic Insurance and Major Medical Insurance.
Continuing Care Retirement Community:
A housing community that provides different levels of care from independent living to nursing home.
Coordination of Benefits:
A system to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100 percent of the claim.
The out-of-pocket amount you pay every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance company pays the rest.
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.
The amount of money you must pay for medical care expenses before your insurance policy starts reimbursing you. This amount must be met each year.
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.
The period of time when no benefits are received during a stay in a long-term care facility.
A rider that eliminates a medical condition from being covered permanently or for a period of time.
Specific conditions or circumstances for which the policy will not provide benefits.
Insurance plans that pay for medical services provided by any hospital or doctor, at any time. Also known as comprehensive plans, or "indemnity" plans.
The list of prescription medicines for which health plans reimburse their members.
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.
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):
Prepaid health plans that work with a network of hospitals and doctors to provide a wide range of health services to their members. For a monthly premium, the HMO covers 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. There are three types of HMOs, which are called group model, staff model, and independent practice associations (IPA).
Home Health Care:
Medical services administered at the patient's home such as nursing care and speech, occupational or physical therapy.
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.