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Insurance
Assistance Insurance Glossary Assignment of Benefits: A written authorization by the patient/insured to make payment to the provider of services (hospital, physician, home care company, etc.) directly. Balance Billing: If a provider chooses not to accept assignment, he or she can “balance bill” the patient for the portion of the charge not recognized by Medicare. Basic Benefits: Refers to the portion of the insurance policy which generally provides coverage for inpatient services: room and board, surgery, drug therapy, physician services, etc. Beneficiary: A person entitled to insurance benefits under the insurance plan; a patient. “Cap”: The maximum length of time or dollar amount that a plan will continue to pay benefits; also referred to as “contract maximum.” Carrier: A private insurer that contracts on a regional basis with the Medicare program to process and pay claims. Also a term generally to describe an insurer. Centers for Medicare & Medicaid Services: A branch of the federal government's Department of Health and Human Services that administers the Medicare program. Charge-Based: Reimbursement based upon billed fees for physician's services. Claim Form: Requests for payment are submitted to insurers on claim forms. Claim forms include spaces for showing the patient's name and address, diagnosis, documentation of medical necessity and kinds of services received. Coding: Several coding systems are used to describe patients and the services they receive in the health care system. These are used on medical records and billing forms. Co-Payment: A percentage of medical costs which the patient is required to pay, usually up to a certain limit. Cost-Based: Reimbursement methodology typically used to pay institutions on the basis of accounting cost audits. The books of the provider are examined in an effort to avoid paying profits and unallowed items. Coverage: The products and services your health plan is willing to pay for. Deductible: A flat amount that the patient is automatically responsible for paying before the insurance plan begins to pay benefits. Effective Date: The date that coverage begins for the insured. Eligibility: The screening method used by an insurance company or government program to determine whether the patient qualifies for benefits. Exclusions: Illnesses, injuries, devices, procedures, or conditions for which the policy will not pay. Explanation of Medical Benefits: This form is sent to patients to report on the status of their insurance claim. It outlines the services for which a bill was received, describes whether the service is covered and delineates the reimbursement that will be made for the service or product. Fee-For-Service: A predetermined charge for a given medical service. Fee Screen: Many insurers established a price cap, also called a fee screen, on the total they will pay for a service or product. Group Health Insurance: An arrangement for insuring a number of people under a single, master insurance policy. Health Maintenance Organization (HMO): A prepaid health plan that provides comprehensive benefits using certain health care professionals, at times in specified locations, generally within certain geographic areas. Health Insurance and Portability Act of 1996 (HIPAA): Guarantees availability of individual health insurance coverage without pre-existing limitations to certain individuals who have lost group coverage. Individual Insurance: Policies that provide protection to the policy holder and/or his or her family. Sometimes called personal insurance as distinct from group insurance. Insured/Policyholder: The person for whom the insurance policy is registered under. Lifetime Maximum: The maximum amount that the insurance company will pay for medical expenses. This amount may be listed as the maximum amount for each illness or condition. Or it may be listed as total costs paid from a portion of a policy; e.g. inpatient expenses vs. outpatient. (see "Cap" above) Major Medical: Refers to the portion of the insurance policy which usually provides coverage for outpatient services: doctor's office visit, outpatient pharmacy services, home therapy, etc Medicaid: A federally and state funded program for low-income people. Eligibility criteria will vary by state but are usually tied to income and assets. Medical Necessity: In order to be financed by an insurer, a service must be medically necessary. Medicare: A federally funded medical insurance program for people age 65 and over, individuals with end stage renal disease, or those who qualify for Social Security disability. Open Enrollment: A time period when a person can obtain insurance coverage or change insurance carriers without penalty for a pre-existing condition. This opportunity may be available from some employers on an annual basis. Out-of-Pocket Expenses: Those medical expenses that an insured must pay that are not covered under the group contract. Pre-Existing Condition Clause: Any medical, obstetrical or psychiatric condition that the patient had at the time the plan became effective. If your plan contains this clause there is usually a defined waiting period beyond the effective date of the plan before the plan will make payment for treatment of the preexisting medical condition. Preferred Provider Organization (PPO): A group of health care providers (physicians, hospitals, and other providers) located within a specific geographical area that have contracted with an entity (a physicians' group or hospital, for example) to provide health care services. Premium: The payment a subscriber must pay in order to maintain medical benefits. Primary Care Physician (PCP): The network physician designated by an employee (and each of his or her dependents) to serve as that employee's entry into the health care system. The PCP often is reimbursed through a different mechanism than are other network providers. This physician sometimes is referred to as the “gatekeeper.” Primary Coverage: The insurance plan that is required to pay benefits first based on state and federal insurance regulations. Provider: Refers to any party that delivers health care services. For example, can be used to describe doctors, hospitals, or suppliers. Reimbursement: The amount the plan pays for a particular product or service. Your plan may reimburse the full amount charged by your doctor, pharmacy, or hospital; or it may reimburse a percentage or set amount. Secondary Coverage: An insurance plan that is required to pay benefits after the primary plan has paid or denied payment for medical expenses. Stoploss/Out-of-Pocket Expense: The maximum amount of money an insured individual is required to pay (as a deductible or co-pay) before the plan will pay benefits at 100 percent. Utilization Review: The process of evaluating the appropriateness, necessity and quality at medical care for purposes of insurance coverage. REFERENCES: Guide to Health Insurance. The Health Insurance Association of America, Washington D.C., 1997. Choosing and Using a Health Plan. U.S. Department Health and Human Services and the Health Insurance Association of America. AHCPR Publication No. 97-0011, March 1997. |
