A bodily injury (other than intentionally self-inflicted injury) sustained by a covered person while the insurance is in force, and which is the direct cause of the loss, independent of disease or bodily infirmity.
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
Adjusted Gross Income (AGI)
Your total (or “gross”) income for the tax year, minus certain adjustments you’re allowed to take. Adjustments include deductions for conventional IRA contributions, alimony paid, student loan interest, and more. Adjusted gross income appears on IRS Form 1040, line 37.
To report expected income on your Marketplace health insurance application, you can start with your most recent year’s adjusted gross income and update it based on income and household changes you expect for the coverage year.
The Marketplace uses a different figure, called modified adjusted gross income (MAGI), to determine eligibility for savings. MAGI is not a line on your tax return.
Advance Premium Tax Credit (APTC)
A tax credit you can take in advance to lower your monthly health insurance payment (or “premium”). When you apply for coverage in the Health Insurance Marketplace, you estimate your expected income for the year. If you qualify for a premium tax credit based on your estimate, you can use any amount of the credit in advance to lower your premium.
- If at the end of the year you’ve taken more premium tax credit in advance than you’re due based on your final income, you’ll have to pay back the excess when you file your federal tax return.
- If you’ve taken less than you qualify for, you’ll get the difference back.
Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).
The law has 3 primary goals:
- Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
- Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)
- Support innovative medical care delivery methods designed to lower the costs of health care generally.
Licensed by the state and has met state mandate education requirements. Gathers census data, prepares proposals, makes presentations to businesses, explains benefits to employers, and employees, does field underwriting when required, delivers policies and certificates, assists in handling claims, performs other related tasks required by the employer or individual.
Services, other than those provided by a physician or hospital, which are related to a patient’s care, such as laboratory work, x-rays and anesthesia.
Annual Deductible Combined
Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay.
A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.
Arkansas Continuation Act
AR Code 23-86-114 & 115 applies to a company that has less than 20 employees and is not COBRA eligible. It allows an employee that has been covered under the employers group plan for at least 3 months prior to be eligible to continue benefits for up to 120 days after termination of employment. The termed employee is responsible for notifying his/her previous employer that they wish to continue coverage and must pay the premium on a monthly basis and in advance to the policyholder (employer).
Attending Physicians Statements (APS)
A written statement provided by a person’s physician, that describes the patient’s diagnosis, course of treatment, and prognosis.
A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside the Marketplace begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.
Brand Name Drug
Any prescription medication that has a patented trade name separate from its generic or chemical designation.
Bronze Health Plan
One of 4 plan categories (also known as “metal levels”) in the Health Insurance Marketplace. Bronze plans usually have the lowest monthly premiums but the highest costs when you get care. They can be a good choice if you usually use few medical services and mostly want protection from very high costs if you get seriously sick or injured.
Note: Bronze plan deductibles can be very high. This means you could have to pay thousands of dollars of health care costs yourself before your plan starts to pay its share.
All health plans in all categories provide free preventive services, and some plans offer other services at low or no cost before you meet your deductible.
The period beginning January 1 of any year through December 31 of the same year.
A process whereby a covered person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner.
Catastrophic Health Plan
Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don’t cover any benefits other than 3 primary care visits per year before the plan’s deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a catastrophic plan, you must be under 30 years old OR get a “hardship exemption” because the Marketplace determined that you’re unable to afford health coverage.
Certificate of Coverage
A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company.
Information a medical provider or insured submits to an insurance company to request payment for medical services provided to the insured.
COBRA (Consolidated Omnibus Budget Reconciliation Act)
A federal law that, among other things, requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance has been terminated if they undergo a qualifying event. Please refer to the Department of Labor for more information.
A method of cost-sharing in a health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.
A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.
The period of time from the effective date of the contract to the expiration date of the contract.
Coordination of Benefits (COB)
A provisions in the contract that applies when a person is covered under more than one medical plan. It requires that payment of benefits be coordinated by all plans to eliminate over insurance or duplication of benefits.
A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.
Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20.
- If you’ve paid your deductible: You pay $20, usually at the time of the visit.
- If you haven’t met your deductible: You pay $100, the full allowable amount for the visit.
Cost Sharing Reduction (CSR)
A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. In the Health Insurance Marketplace, cost-sharing reductions are often called “extra savings.” If you qualify, you must enroll in a plan in the Silver category to get the extra savings.
- When you fill out a Marketplace application, you’ll find out if you qualify for premium tax credits and extra savings. You can use a premium tax credit for a plan in any metal category. But if you qualify for extra savings too, you’ll get those savings only if you pick a Silver plan.
- If you qualify for cost-sharing reductions, you also have a lower out-of-pocket maximum — the total amount you’d have to pay for covered medical services per year. When you reach your out-of-pocket maximum, your insurance plan covers 100% of all covered services.
- If you’re a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.
An individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement.
The period of time a covered person was covered by a health plan or insurance contract defined as creditable coverage in the provisions of the Health Insurance Portability and Accountability Act of 1996. Common health plans and insurance contracts providing creditable coverage includes: Employer Group Health Insurance, Individual Comprehensive Health Insurance, Medicare, Medicaid, CHAMPUS, and a State Health Benefits Risk Pool. Any continuous sixty-three (63) day period during which the covered person was not covered will start a new period of creditable coverage.
Data Matching Issue (Inconsistency)
A difference between some information you put on your Marketplace health insurance application and information we have from other data sources.
The data matching issue may involve your annual income, citizenship, immigration status, or other matters. When you get a notice about a data matching issue, you’ll need to send documents to verify the information you put on your application. If you don’t do it by the date included in the notice, you could lose your health insurance or any savings you’re getting to help pay for it.
The amount of eligible expenses a covered person must pay each year from his/her own pocket before the plan will make payment for eligible benefits.
Deductible Carry Over Credit
Charges applied to the deductible for services during the last 3 months of a calendar year which may be used to satisfy the following year’s deductible.
A covered person who relies on another person for support or obtains health coverage through a spouse, parent or grandparent who is the covered person under a plan.
Donut Hole, Medicare Prescription Drug
Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
The date insurance coverage begins.
A dependent of a covered person (spouse, child, or other dependent) who meets all requirements specified in the contract to qualify for coverage and for whom premium payment is made.
The amount of time you must be off work due to a covered condition before benefits begins.
The lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan.
Employees enroll in a group health plan by selecting from the health plan options offered by the employer and signing the appropriate forms provided to the employer by the insurance company. Enrolling employees are the number of employees that participate in a group health plan.
Essential Health Benefits
A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services.
Plans must offer dental coverage for children. Dental benefits for adults are optional.
Specific services may vary based on your state’s requirements. You’ll see exactly what each plan offers when you compare plans.
Most people must have qualifying health insurance or pay a fee. But people who qualify for a health coverage exemption don’t have to pay the fee. Exemptions are granted based on certain hardships and life events, health coverage or financial status, membership in some groups, and other circumstances.
Explanation of Benefits (EOB)
The statement sent to an insured by their health insurance company listing services provided, amount billed, eligible expenses and payment made by the health insurance company.
Exclusions are specific conditions or circumstances for which the policy will not provide benefits.
Family and Medical Leave Act (FMLA)
A Federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member. When on leave under FMLA, you can continue coverage under your job-based plan.
Federal Birthday Rule
A guideline used in coordination of benefits (COB) of a dependent child’s coverage. The coverage of the parent whose birthday is first in the year is primary.
Federal Maternity Leave Act (FMLA)
A law that determines a worker’s right to maintain employment status in event of an extended medical leave for that worker or an immediate family member. Refer to the Department of Labor for more information on the Federal Medical Leave Act.
Federal Poverty Level (FPL)
A measure of income issued every year by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
Fee for Services
A methods of charging for each visit or service. This method is arranged between a physician and the insurance company.
Flexible Spending Account (FSA)
An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.
There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year.
(Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements.)
A list of medications that your provider may prescribe that would be covered under the pharmacy benefit at a low co-payment. Formularies are used to control rising medical costs and keep co-payments low but still provide the best value and not compromise quality of care.
A willful attempt to deceive another party by providing false or misleading information.
Full-Time Employee (FTE)
Any employee who works an average of at least 30 hours per week for more than 120 days in a year. Part-time employees work an average of less than 30 hours per week.
Fully Insured Plan
The employer pays the entire premium and, in return, transfers all of the risk and responsibility for claims payments to the insurance company.
Any chemically equivalent reproduction of a Brand Name Medication whose patent has expired.
Gold Health Plan
One of 4 health plan categories (or “metal levels”) in the Health Insurance Marketplace. Gold plans usually have higher monthly premiums but lower costs when you get care. Gold may be a good choice if you use a lot of medical services or would rather pay more up front and know that you’ll pay less when you get care.
A short period — usually 90 days — after your monthly health insurance payment is due. If you haven’t made your payment, you may do so during the grace period and avoid losing your health coverage.
The grace period for health insurance is usually 90 days if both of the following are true:
- You have a Marketplace plan and qualify for advance payments of the premium tax credit.
- You’ve paid at least one full month’s premium during the benefit year so far.
Note: The length of your grace period may be different if you don’t qualify for a premium tax credit. Contact your State Department of Insurance (DOI) for information on grace periods in your state.
Grandfathered Health Plan
As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).
The purpose of Guaranty Association is to assure that policy and contract owners will be protected, within certain limits, in the unlikely event that a member insurer becomes financially unable to meets its obligations. In Arkansas, the name of the state law that providers for this safety net is called the Arkansas Life and Disability insurance Guaranty Association Act.
Health Insurance Portability & Accountability Act (HIPAA)
An act that was signed into law in 1996. This Act is very broad in nature and brought uniformity to many areas of health insurance such as: definition of pre-existing conditions, acceptance of group health insurance applicants regardless of medical history, maternity, and creditable coverage. Contact the Department of Labor for more information on HIPAA.
HMO (Health Maintenance Organization)
An organization that provides a wide range of comprehensive health care services through a designated group, or network of doctor’s, hospitals, labs and other providers. To receive benefits, you must first see the Primary Care Physician you selected for care or a referral, except in the case of an emergency. Your choice of doctors is restricted to those in network. If you are an HMO member and you do not use the doctors hospitals and clinics that participate in your plan’s network, you will usually bear the cost of those medical services.
Coverage by contract whereby one party undertakes to indemnify or guarantee another against loss by a specified contingency.
Maximum amount of benefits available to a member during their lifetime. All benefits furnished are subject to this maximum unless stated as unlimited.
Long Term Care
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.
The proportion of paid claims and administrative fees incurred by the insurance carrier (or plan administrator) in relation to the amount of premium dollars or funding received.
A healthcare system under which physicians, hospitals, and other health care professionals are organized into a group or “network” in order to manage the cost, quality and access to health care. Managed care organizations include Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs).
Service or care for a woman during pregnancy.
A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.
Medicare Part A
The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization, and hospice care.
Medicare Part B
The Medicare component that provides benefits to cover the costs of physicians’ professional services, whether the services are provided in a hospital, a physician’s office, an extended-care facility, a nursing home, or an insured’s home.
The willful act of altering information in such a way that it diminishes or lessens the actual nature of the information presented.
MSA (Medical Savings Account)
A tax-advantage personal savings account used in conjunction with a high deductible health policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses, including annual deductible and co-payments. This can be set up through your CPA or tax advisor.
The group of physicians, hospitals, and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members.
Newborns’ and Mothers’ Health Protection Act (NMHPA)
A law which specifies that group health plans or group healthcare insurers cannot mandate that hospital stays following childbirth be shorter than 48 hours for normal deliveries or 96 hours for cesarean births.
Non-contracted or unapproved health providers who are outside a managed care arrangement.
An informal name sometimes used to refer to the health coverage plans available through the Health Insurance Marketplace. Obamacare often also refers to the Affordable Care Act. Signed into law March 23, 2010 by President Obama, which is where the term “Obamacare” comes from.
Failing to disclose information whether or not intentional.
A provision that specifies that plan members may self-refer to a specialist, either in-network or out-of-network, at full benefit or at a reduced benefit, without first obtaining a referral from a primary care provider
Open Enrollment Period
The yearly period when people can enroll in a health insurance plan.
Outside the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You’re eligible if you have certain life events, like getting married, having a baby, or losing other health coverage.
- Job-based plans may have different Open Enrollment Periods. Check with your employer.
- You can apply and enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time of year.
Out Of Network
Medical services obtained by managed care plan members from unaffiliated or non-contracted health care providers. In many plans, such care will be reimbursed at lower benefit levels.
Out of Pocket Maximum
The total payments that must be paid by a covered person (i.e., deductibles and coinsurance) as defined by the contract. Once this limit is reached, covered health services are paid at 100% for health services received during the rest of that calendar year.
A medical provider who has been contracted to render medical services or supplies to insured’s at a pre-negotiated fee. Providers include hospitals, physicians, and other medical facilities.
Patient Protection and Affordable Care Act
The first part of the comprehensive health care reform law enacted on March 23, 2010.
The law was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is usually used to refer to the final, amended version of the law. (It’s sometimes known as “PPACA,” “ACA,” or “Obamacare.”)
The law provides numerous rights and protections that make health coverage more fair and easy to understand, along with subsidies (through “premium tax credits” and “cost-sharing reductions”) to make it more affordable.
The law also expands the Medicaid program to cover more people with low incomes.
A payment (“fee,” “fine,” “individual mandate”) you make if you don’t have health insurance that counts as qualifying health coverage. The penalty in 2016 and 2017 for not having health coverage is $695 for each person on your tax return who isn’t covered ($347.50 per child), or 2.5% of your household income, whichever is more.
- You owe a fee for any month you, your spouse, or your tax dependents don’t have qualifying health coverage.
- You’ll pay the fee when you file your federal income tax return.
- If you’re uncovered just some months of the year, you pay 1/12 of the penalty for each month you’re uninsured. If you’re uncovered for only 1 or 2 consecutive months, you don’t have to pay the fee at all.
People with very low incomes and others with special circumstances may be eligible for exemptions from the requirement to have health insurance. If you qualify for an exemption, you won’t have to pay the fee.
Physician-Hospital Organization (PHO)
Group practice arrangement that occurs when hospitals and physicians organize for purposes of contracting with managed care organizations. These relationships are formally organized, contractual, or corporate in character and include physicians outside the boundaries of a hospital’s medical staff.
Point-Of-Service (POS) Product
A healthcare option that allows members to choose at the time medical services are needed whether they will go to a provider within the plan’s network or seek medical care outside the network.
A general term used to describe a condition that is determined to have existed some time prior to the effective date of coverage. HIPAA defines a six (6) month “look back” period prior to the insured’s enrollment date in order to determine if a condition was pre-existing. Supplemental insurance carriers and many individuals carriers are not subject to the HIPPA definition of pre-existing. Of those types of insurance carriers, many still use the “prudent person” clause in order to determine if a condition existed prior to the date of coverage.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
A utilization management technique that requires a plan member or the physician in charge of the member’s care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Preferred Provider Organization (PPO)
A health care delivery arrangement, which offers insured’s access to participating providers at reduced costs. PPOs provide insured’s incentives, such as lower deductibles and co-payments, to use providers in the network. Network providers agree to negotiated fees in exchange for their preferred provider status.
A prepaid payment or series of payments made to a health plan by purchasers, and often plan members, for medical benefits
Premium Tax Credit
A tax credit you can use to lower your monthly insurance payment (called your “premium”) when you enroll in a plan through the Health Insurance Marketplace. Your tax credit is based on the income estimate and household information you put on your Marketplace application.
If your estimated income falls between 100% and 400% of the federal poverty level for your household size, you qualify for a premium tax credit.
You can use all, some, or none of your premium tax credit in advance to lower your monthly premium.
- If you use more advance payments of the tax credit than you qualify for based on your final yearly income, you must repay the difference when you file your federal income tax return.
- If you use less premium tax credit than you qualify for, you’ll get the difference as a refundable credit when you file your taxes.
Primary Care Physician (PCP)
A physician that is responsible for providing, prescribing, authorizing and coordinating all medical care and treatment.
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
A physician, hospital, health professional and other entity or institutional health care provider that provides a health care service.
Qualified Health Plan
An insurance plan that’s certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All qualified health plans meet the Affordable Care Act requirement for having health coverage, known as “minimum essential coverage.”
Qualifying Life Event (QLE)
A change in your situation — like getting married, having a baby, or losing health coverage — that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.
There are 4 basic types of qualifying life events. (The following are examples, not a full list.)
- Loss of health coverage
- Losing existing health coverage, including job-based, individual, and student plans
- Losing eligibility for Medicare, Medicaid, or CHIP
- Turning 26 and losing coverage through a parent’s plan
- Changes in household
- Getting married or divorced
- Having a baby or adopting a child
- Death in the family
- Changes in residence
- Moving to a different ZIP code or county
- A student moving to or from the place they attend school
- A seasonal worker moving to or from the place they both live and work
- Moving to or from a shelter or other transitional housing
- Other qualifying events
- Changes in your income that affect the coverage you qualify for
- Gaining membership in a federally recognized tribe or status as an Alaska
- Native Claims Settlement Act (ANCSA) Corporation shareholder
- Becoming a U.S. citizen
- Leaving incarceration (jail or prison)
- AmeriCorps members starting or ending their service
Reasonable & Customary (R & C)
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community
Primary care physician-directed transfer of a patient to a specialty physician or specialty care.
A health plan, under which an employer or other groups sponsor, rather than an MCO or insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as a self-insured plan.
Special Enrollment Period
A 30-day period during which time an employee’s dependent may enroll in the plan, after his or her initial eligibility period and not be considered a late enrollee. This time usually follows a qualified family status change.
A healthcare professional whose practice is limited to a certain branch of medicine, specific procedures, certain age categories of patients, specific body systems, or certain types of diseases.
Standard Industrial Classification (SIC) Codes
The Standard Industrial Classification is a statistical classification that covers the entire field of economic activities and defines industries in accordance with the composition and structure of the economy.
State Children’s Health Insurance Program (SCHIP)
A program, established by the Balanced Budget Act, designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs
The point or dollar amount, at which the insurance company starts paying 100%.
Replacing an existing employer sponsored insurance plan with another.
Termination Of Coverage
The point or date that benefits ends.
Termination of Employment
The point or date that employment ends.
The first period in which the covered person is eligible to enroll in the plan.
The act of reviewing and evaluation prospective insured’s for risk assessment and appropriate premium.
Usual Customary & Reasonable (UCR)
These factors, or combinations of these factors, are often used to determine the amount of money an insurance carrier will allow for services.
Benefits as they pertain to sight.
Date of hire and the employee’s eligibility to qualify for a plan of insurance or if already insured that time period before one is eligible for benefits (i.e. elimination period)
Preventive care programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes.
Women’s Health and Cancer Rights Act (WHCRA)
A law that requires health plans that offer medical and surgical benefits for mastectomy to provide coverage for reconstructive surgery following mastectomy.