We've compiled a list of common health care and health insurance related terms to help you better understand words commonly used in our industry and on our web site.
Terms appear in alphabetical order. To use the glossary, please choose the first letter of the term you would like to view.
The amount of money per enrollment classification paid to a carrier for medical coverage. Rates are usually charged on a monthly basis.
The process of determining rates, or the cost of insurance, for individuals, groups or classes of risks.
A procedure performed to restore a bodily function, or to correct a deformity resulting from disease, injury, trauma, congenital anomalies or developmental abnormalities, or previous medically necessary treatment (e.g., surgery, radiation therapy). The characteristics to be corrected are considered to be outside the range of normal. Examples of such conditions include cleft lip, deforming birthmarks and burn scars.
A condition which causes successive periods of care that are separated:
- By one or more days; and
- By less than 180 days.
Successive periods of care due to a recurring condition are not subject to a new elimination period.
The process of enrolling an individual member as new following termination of coverage. Because of the time lapse between termination and re-enrollment, continuity of benefits is lost. Members are assigned new effective dates and may be subject to contract waiting periods.
The recommendation by a physician and/or health plan for a member to receive care from a different physician or facility.
REGISTERED NURSE (RN)
A nurse who has graduated from a formal program of nursing education (diploma school, associate degree or baccalaureate program) and is licensed by the appropriate state authority.
(a) Restoration of a disabled person to a meaningful occupation. (b) A provision in some disability policies that provides for continuation of benefits or other financial assistance while a disabled insured is retraining or attempting to resume productive employment.
The resumption of coverage under a policy which has lapsed.
The practice of one insurance company having insurance from a second company for the purpose of protecting itself against part or all of the losses it might incur in the process of honoring the claims of its policyholders.
A refusal to accept an application or a refusal to pay a claim.
Continuance of coverage under a policy beyond its original term by the acceptance of a premium for a new policy term.
A set, hospital-free period of time which must be satisfied after a hospital admission before a member's contracted benefit days renew.
Accounts set up to report the liabilities faced by an insurance company under outstanding insurance policies. The company sets the amount of reserves in accord with its own estimates, state laws and recommendations of supervisory officials and national organizations. Reserves are obligated amounts and have four principle components; reserves for future benefits; and other reserves for various special purposes, including contingency reserves for unforeseen circumstances.
That portion of the cost of a medical benefit program which is kept by the insurance company or health plan to cover internal costs or to return a profit. In addition to administrative costs, our total retention includes other elements such as risk, contingency, nongroup subsidy, etc.
The premium/dollars received by the health plan from the employer group(s) for health care and administrative services. See also premium.
The amounts earned from a company's sales of products and services to its customers.
A provision added to a member contract whereby the scope of its coverage is increased or restricted.
ROUTINE EYE CARE
Consists of eye examination or refractions reported without a symptomatic condition, disease, injury or defect related to the eye.