Group Health Insurance Glossary

A

Accreditation: Refers to the "seal of approval" your insurance carrier may or may not bestow on a given healthcare facility. Having received an accreditation indicates that a particular care facility meets service quality standards set by private, nationally recognized groups that monitor the quality of services at healthcare facilities.

Ambulatory Care: This refers to any type of healthcare service that doesn’t require an overnight hospital stay.

Ancillary Services: These are healthcare related services, other than those you’ve received from a physician or hospital, but are nonetheless part and parcel of patient care; it’s everything from anesthesia to lab work to x-rays, etc.

B

Benefit Design: The process by which the benefits or level of benefits that a health plan will offer its members is determined.

Board-Certified: This refers to a physician with specialized training in a particular area of medicine.

C

Cafeteria Plan: These are employee benefit plans that allow employees to choose from an assortment of benefit types in order to formulate a healthcare plan that will best suit your needs. They are sometimes known as flexible benefit plans.

Claim Form: This is an application for benefits reimbursement under a health plan.

Claims Administration: The department responsible for processing (i.e. receiving, reviewing and adjudicating) your insurance claims.

COBRA: The Consolidated Omnibus Budget Reconciliation Act requires every group health plan with twenty or more participants to allow employees to continue their group health coverage for a limited period after a qualifying event (job loss, reduction of work hours, etc.) causes a loss of coverage.

Co-Insurance Rate: This refers to the cash amount that you will be required to pay on each medical claim.

Co-Payment: The specific dollar amount that you will have to pay “out-of-pocket” for a specific service when that service is rendered.

D

Deductible: The flat amount that you will be responsible for annually before your insurance carrier will make reimbursement payments.

E

Elimination Rider: This is a health plan amendment that permanently excludes you from coverage for a particular medical condition. Note: There are certain states that do not permit elimination riders.

EPO: The acronym for Exclusive Provider Organization. EPOs are healthcare plans similar in most respects to Preferred Provider Organizations—in terms of operation, administration, and structure, but they do not provide coverage for out-of-network care.

F

Formulary: This is a listing, classified by therapeutic category, of the drugs preferred by health providers.

G

Guaranteed Issue: This is a health plan that must allow you to enroll regardless of your status, age, gender.

H

HIPAA: The Health Insurance Portability and Accountability Act is a federal law that established an outline for the requirements that group health plans, managed care organizations and insurance carriers have to satisfy in order to provide insurance coverage in individual and group healthcare markets.

Health Maintenance Organizations: Better known as HMOs, these popular health plans provide comprehensive medical services to their members in return for a fixed, pre-paid fee. When you choose an HMO, you’ll be required to choose what’s known as a “primary-care physician” who will thereafter be responsible for administering your healthcare, making specialist referrals, etc. You will also have to use the doctors and hospitals who are members of your HMO Organization’s network.

Health Savings Accounts: Established by federal legislation passed in late 2003, HSAs combine high deductible health plans with tax-favored savings accounts.

High Deductible Health Plan: The HDHP is a health insurance plan that carries a minimum deductible of $1,000.00 for individuals and $2,000.00 for families.

M

Managed Care Organization: Simply put, MCO’s are healthcare plans that manage your healthcare expenses by managing its delivery. For the most part, this involves partnerships with healthcare providers that allow them to deliver their services on a per-member, per-month (capitated) basis.

Medicaid: The jointly State and Federally administered and funded healthcare program for low- income and disabled persons.

Medicare: The federally administered health insurance program that was authorized in 1965 to care for seniors; covering the costs of medical care, hospitalization, and certain health related services.

Medicare Supplement Insurance: These are health plans provided to groups or individuals that help fill in the gaps between your actual healthcare needs and the coverage provided by Medicare.

N

Network Provider: The healthcare providers who have contractual relationships with your insurance carrier. This contractual relationship establishes pre-set charges for specific services, clinical protocols, and overall standards of care.

O

Open Access: This refers to a health plan provision that guarantees plan members the right to refer themselves to specialists at either full benefit or a reduced benefit, without first having to get approval.

Out-of-Pocket Maximum: The cash limits set on what you’ll have to pay for your healthcare annually.

P

Pre-Existing Condition: This refers to any medical condition that you received treatment, medication, diagnosis, or for consultation prior to the effective date of a new health plan.

Preferred Provider Organization: PPOs are healthcare benefit programs that will supply you with services at a discounted cost by providing incentives to use designated health providers, but that will also provide coverage for health services rendered by providers who are not a part of your PPO’s network.

Primary Care Physician: Your primary care physician will be your main care giver, serving as the first “point-of-contact” for your healthcare needs, referring you to specialist providers and more.

Q

Qualifying Medical Expenses: Refers to any health or medical expenditure that is traditionally covered by your health plan.

R

Referral: This is simply a “go ahead” from your primary-care physician that will allow you to see a specialist.

S

Service Area: This refers to the geographic area in which your health plan will accept members.

U

Urgently Needed Care: The care you’ll receive for unexpected injuries or sudden illnesses that require immediate but not emergency medical care. Your primary care physician will generally provide your urgently needed care.

W

Workers Compensation: The basic health plan that employers are legally required to have in order to cover employees who are injured or fall ill on the job.