Access to Care Resources



Actuary: A mathematician working for a health insurance company responsible for determining what premiums the company needs to charge based in large part on claims paid versus amounts of premium generated.

Admitting Privileges: The right granted to a doctor to admit patients to a particular hospital.

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

Agent: Licensed salespersons that represent one or more health insurance companies and present their products to consumers.

Allowed Expenses: The maximum amount a plan pays for a covered service.

Association: A group. Often, associations can offer individual health insurance plans specially designed for their members.

Benefits: Medical services for which your insurance plan will pay.

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 generic.

Broker: Licensed insurance salesperson who obtains quotes and plans from multiple sources information for clients.

Capitation: A flat monthly fee that a health plan pays to a provider (doctor, hospital, lab, etc.) to take care of a patient’s needs.

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 healthcare services.

Certificate of Insurance: The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what is covered, what is not, and dollar limits.

Claim: A notice to the insurance company that a person received care covered by the plan. A claim also may be a request for payment and will state so.

COBRA: Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated.

Co-insurance: A term that describes a shared payment between an insurance company and an insured individual, usually described in percentages. For example, the insurance company agrees to pay 80 percent of covered charges and the individual picks up the remaining 20 percent.

Co-payment: The insured individual’s portion of the cost, usually a flat predictable dollar amount. Under many plans, co-payments are made at the time of the service and the health plan pays for the remainder of the fee.

Coverage: What the health plan does and does not pay for. Coverage includes almost everything mentioned in this booklet: benefits, deductibles, premiums, limitations, etc.

Covered Expenses: What the insurance company will consider paying for as defined in the contract. For example, under some plans generic prescriptions are covered expenses, while brand name prescriptions may be covered at a different reimbursement rate or not at all.

Deductible: A portion of the covered expenses (typically $100, $250 or $500) that an insured individual must pay before benefits are paid by the insurance plan. Deductibles are standard in many indemnity and PPO policies, and are usually based on a calendar year.

Denial of Claim: Refusal by an insurance company to honor a request by an individual (or his or her provider) to pay for healthcare services obtained from a healthcare professional.

Dependents: 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.

Diagnosis: The art or act of identifying a disease from its signs and symptoms.

Effective Date: The date your insurance is to actually begin. You are not covered until the policy’s effective date.

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.

Exclusions: Medical services that are not covered by an individual’s insurance policy.

Explanation of Benefits: The insurance company’s written explanation to a claim, showing what they paid and what the client must pay.

External Review: A review of a denied claim from an outside agency other than your insurance provider. To find out if your insurance provider offers an external review or provides contact information for the agency reviewing the claim, view the “Exclusions” section of your insurance policy.

Generic Drug: A “twin” to a “brand name drug” once the brand name company’s patent has run out and other drug companies are allowed to sell a duplicate of the original.

Group Insurance: Coverage through an employer or other entity that covers all individuals in the group.

Health Maintenance Organizations (HMOs): Health Maintenance Organizations represent “pre-paid” or “capitated” insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided. Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility or in a physician’s own office (as with IPAs).

HIPAA: A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of healthcare data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for healthcare patients, providers, payors (or plans) and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable healthcare. Full name is “The Health Insurance Portability and Accountability Act of 1996.”

Indemnity Health Plan: Indemnity health insurance plans are also called “fee-for-service.” These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of healthcare services, and the insurance company (or self-insured employer) pays the other percentage. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their healthcare professionals.

Independent Practice Associations (IPA): IPAs are similar to HMOs, except that individuals receive care in a physician’s own office, rather than in an HMO facility.

In-network: Providers or healthcare facilities which are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.

Lifetime Maximum Benefit (or Maximum Lifetime Benefit): the maximum amount a health plan will pay in benefits to an insured individual during that individual’s lifetime.

Limitations: A limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.

Long-Term Care Policy: Insurance policies that cover specified services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include nursing care, home healthcare services and custodial care.  

Long-term Disability Insurance: Pays the insured individual a percentage of their monthly earnings if they become disabled.

Length of Stay (LOS): LOS refers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.

Managed Care Plan: A term that typically refers to an HMO, Point of Service, EPO, or PPO; any health plan with specific requirements, such as pre-authorization or second opinions, which enable the primary care physician to coordinate or manage all aspects of the patient’s medical care.

Maximum Out-of-Pocket: The most money you can expect to pay for covered expenses. The maximum limit varies from plan to plan. Some companies count deductibles, co-insurance, or co-payments toward the limit, others do not. Once the maximum out-of-pocket has been met, many health plans pay 100 percent of certain covered expenses.

Medigap Insurance Policies: Medigap insurance is offered by private insurance companies, not the government. It is not the same as Medicare or Medicaid. These policies are designed to pay for some of the costs that Medicare does not cover.

Multiple Employer Trust (MET): A trust consisting of multiple small employers in the same industry, formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than would be available to each of the employers individually.

Network: A group of doctors, hospitals and other healthcare providers contracted to provide services to insurance company customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of healthcare services. Insured individuals typically pay less for using a network provider.

Open Enrollment: A specified period of time in which employees may change insurance plans and medical groups offered by their employer, without proof of insurability. Open enrollment usually occurs once a year, but check with your employer to be sure.

Out-of-Plan (Out-of-Network): This phrase usually refers to physicians, hospitals or other healthcare providers who are considered non-participants in an insurance plan (usually an HMO or PPO). Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual’s insurance company.

Out-Of-Pocket Maximum: A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company (or self-insured employer) will pay 100 percent for an individual’s healthcare expenses.

Outpatient: An individual (patient) who receives healthcare services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe healthcare facilities where procedures are performed.

Plan Administration: Supervising the details and routine activities of installing and running a health plan, such as answering questions, enrolling individuals, billing and collecting premiums and similar duties.

Pre-Admission Certification: Also called pre-certification review, or pre-admission review. Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate healthcare services (services that are medically unnecessary).

Pre-Admission Review: A review of an individual’s healthcare status or condition, prior to an individual being admitted to an inpatient healthcare facility, such as a hospital. Pre-admission reviews are often conducted by case managers or insurance company representatives (usually nurses) in cooperation with the individual, his or her physician or healthcare provider and hospitals.

Pre-Admission Testing: Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient healthcare facility.

Pre-Authorization: An insurance plan requirement in which you or your primary care physician must notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense.

Pre-Existing Conditions: A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.

Preferred Provider Organizations (PPOs): You or your employer receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care.

Premium: The money paid to an insurance company for coverage. Premiums are usually paid monthly and may be paid in part or in full by your employer.

Primary Care Provider (PCP): A healthcare professional (usually a physician) who is responsible for monitoring an individual’s overall healthcare needs. Typically, a PCP serves as a “quarterback” for an individual’s medical care, referring the individual to more specialized physicians for specialist care.

Provider: Provider is a term used for health professionals who provide healthcare services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other healthcare professionals such as hospitals, nurse practitioners, chiropractors, physical therapists and others offering specialized healthcare services.

Reasonable and Customary Fees: The average fee charged by a particular type of healthcare practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.

Rider: A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).

Risk: The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications’ side effects, exposure to infection or the chance of suffering a medical problem because of a lifestyle or other choice.

Second Opinion: A medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual.

Second Surgical Opinion: These are now standard benefits in many health insurance plans. It is an opinion provided by a second physician, when one physician recommends surgery to an individual.

Short-Term Disability: An injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual’s full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.

Short-Term Medical: Temporary coverage for an individual for a short period of time, usually from 30 days to six months.

Small Employer Group: Generally means groups with less than 100 employees. The definition may vary between states.

Specialist: A physician who practices medicine in a specialty area. Cardiologists, orthopedists, gynecologists and surgeons are all examples of specialists. Under most health plans, family practice physicians, pediatricians and internal medicine physicians are not considered specialists. Some health plans require preauthorization from your primary care physician before you can see a specialist.

State Mandated Benefits: When a state passes laws requiring that health insurance plans include specific benefits.

Stop-Loss: The dollar amount of claims filed for eligible expenses at which point you have paid 100 percent of your out-of-pocket and the insurance begins to pay at 100 percent. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.

Triple-Option: Insurance plans that offer three options from which an individual may choose. Usually, the three options are: traditional indemnity, an HMO and a PPO.

Underwriter: The company that assumes responsibility for the risk, issues insurance policies and receives premiums.

Usual and Customary Charges: The average cost of a specific medical procedure in your geographic area. This is the maximum amount some insurance companies will pay for certain covered expenses. Also referred to as allowed expenses, they reflect the provider’s retail cost of service.

Waiting Period: A period of time when you are not covered by insurance for a particular illness.

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