VISTA HEALTH LEARNING CENTER
Health Insurance Terms Glossary
Allowable Charge: The maximum fee that a health plan will reimburse a provider for a given service.
Ambulatory Care: A general term for care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.
Ambulatory Surgery: Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
Ancillary care: Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.
Anniversary date: The day after a coverage period ends under a health benefits plan. Usually, the month and day that a health benefits plan first goes into effect becomes its anniversary date each year.
Behavioral care services: Assessment and therapeutic services used in the treatment of mental health and substance abuse problems.
Benefits: The portion of the costs of covered services paid by a health plan. For example, if a plan pays the remainder of a doctor's bill after an office visit co-payment has been made, the amount the plan pays is the "benefit." Or, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the "benefit."
Board-certified: Any physician who has completed medical school, internship and residency in his or her chosen specialty and has successfully completed an examination conducted by a group (or board) of peers.
Brand-name drug: A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.
Carrier: A term historically used for licensed insurance companies, although now is sometimes used to include both licensed insurers and HMOs.
Claim: A claim is a request for payment under the terms of a health benefits plan.
Coinsurance: The portion of eligible expenses that plan members are responsible paying, most often after the deductible is met. It's usually determined as a percentage of the total cost.
Consolidated Omnibus Budget Reconciliation Act (COBRA): A federal statute that requires most employers to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time (usually 18 months for employees and dependents who would otherwise lose coverage due to loss of employment or work hour reduction, or 36 months for dependents who would lose coverage for certain reasons other than employment loss by the employee).
Coordination of Benefits: A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate over insurance or duplication of benefits.
Co-payment (copay): Amount that a plan member must pay the provider at the time of service, usually after the deductible is met for eligible expenses. It is usually a flat fee of $10 - $25.
Deductible: The dollar amount that a plan member must pay for eligible health expenses before a traditional health plan kicks in with benefits.
Durable medical equipment: Equipment that can withstand repeated use and is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home.
Exclusive Provider Organization (EPO): A specific type of health plan with a national network of physicians. Plan members can visit specialists without a referral. Members don't need to choose a primary care physician for coverage. An annual deductible is required, and an out-of-pocket maximum applies. Coverage is not available for out-of-network service.
Explanation of benefits (EOB): A statement provided by the health benefits administrator that explains the benefits provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid. A participant typically receives an explanation of benefits with a claim reimbursement check or as confirmation that a claim has been paid directly to the provider.
Formulary: A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost.
Gatekeeper: A primary care physician who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. This traditional primary care physician role is called a "gatekeeper" function. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers.
Generic drug: A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs and are typically less costly.
Health Maintenance Organization (HMO): An organization that arranges a wide spectrum of health care services which commonly include hospital care, physicians' services and many other kinds of health care services with an emphasis on preventive care.
Health Reimbursement Arrangement (HRA): An arrangement in which the participant is reimbursed for covered health expenses by his/her employer up to a predetermined amount. Unused amounts may be carried over to the next year, subject to limits set by the employer.
HIPAA: Health Insurance Portability and Accountability Act of 1996. The law has several parts:
The first part addresses health insurance portability and is designed to protect health insurance coverage for workers and their families when they change or lose their jobs.
Another part of the law is designed to reduce the administrative costs of providing and paying for healthcare through standardization.
The law also includes requirements to protect the privacy of individuals' protected health information. Health plans, providers and other organizations with access to protected health information are covered by the requirements of HIPAA.
Home Health Care: Health services rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies and special outpatient services.
Indemnity plan: A type of health benefits plan under which the covered person pays 100% of all covered charges up to an annual deductible. The health benefits plan then pays a percentage of covered charges up to an out-of-pocket maximum.
In-Network Provider: Any health care provider (physician, hospital, etc.) that belongs to a network. Staying in-network gives members the advantage of significant discounts, helping to stretch their account dollars further.
Inpatient care: Care given to a patient admitted to a hospital, extended care facility, nursing home or other facility.
Managed Care: A system of health care delivery that manages the cost of health care and access to health care providers.
Non-Participating Provider: A medical provider who has not contracted with a health plan.
Occupational Therapy: Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.
Out-of-Network Provider: Any health care provider that does not belong to a network. Members can use their benefits for out-of-network expenses, but miss out on in-network discounts.
Out-of-Pocket: Co-payments, deductibles or fees paid by participants for health services or prescriptions.
Out-of-Pocket Maximum: The most a plan member will pay per year for covered health expenses before the plan pays 100% of covered health expenses for the rest of that year.
Outpatient care: Any health care service provided to a patient who is not admitted to a facility. Outpatient care may be provided in a doctor's office, clinic, the patient's home or hospital outpatient department.
Participating Provider: A physician, hospital, pharmacy, laboratory or other appropriately licensed facility or provider of health care services or supplies that has entered into an agreement with a managed care entity to provide services or supplies to a patient enrolled in a health benefit plan.
Point-of-Service (POS) plan: A health plan allowing the member to choose to receive a service from a participating or non-participating provider, with different benefits levels associated with the use of participating providers.
Precertification: The process of obtaining certification from the health plan for routine hospital stays or outpatient procedures. The process involves reviewing criteria for benefit coverage determination.
Pre-Existing Condition: A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy.
Pre-Existing Condition Limitations: When an employee has a physical or mental condition that existed prior to the effective date of his or her insurance coverage, it is considered a pre-existing condition. Most plans exclude or decrease disability benefits for an illness or injury for which an employee received medical treatment or consultation within a specified time period before becoming covered under the plan. The limitation generally expires after coverage has been in effect for a specified period of time.
Preferred Provider Organization (PPO) plan: A specific type of health plan with a national network of physicians. Plan members can visit physicians both in and out of the network, and can visit specialists without a referral. Members don't need to choose a primary care physician for coverage. An annual deductible is required, and an out-of-pocket maximum applies.
Preventive care: Medical and dental services aimed at early detection and intervention.
Primary Care Physician (PCP): A physician, usually a family or general practitioner, internist or pediatrician, who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers. Each covered family member chooses his or her own PCP from the network's physicians.
Urgent Care: When prompt medical attention is needed in a non-emergency situation, that's called "urgent" care. Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections. Urgent situations are not considered to be emergencies.
Usual, Customary or Reasonable (UCR): The amount reimbursed to providers based on the prevailing fees in a specific area.
Relevant Links
New York State Insurance Department
The Insurance Department is responsible for supervising and regulating all insurance business in New York State.
http://www.ins.state.ny.us/hp97wel.htm
Healthy New York
Healthy NY is a state program that offers subsidized and standardized insurance plans (offered by all HMO's) to qualifying Individuals, Sole Proprietorships & small Groups.
http://www.ins.state.ny.us/healthny.htm
Child Health Plus
New York State has a health insurance plan for kids, called Child Health Plus. Depending on your family's income, your child may be eligible.
http://www.health.state.ny.us/nysdoh/chplus/
Elederly Pharmaceutical Insurance Coverage (Epic) Program
EPIC is a New York State sponsored prescription plan for senior citizens who need help paying for their prescriptions.
http://www.health.state.ny.us/nysdoh/epic/faq.htm