HEALTH GLOSSARY
Benefit
"Amount payable by the insurance company to a claimant, assignee, or beneficiary when the
insured suffers a loss."
Capitation
"Capitation represents a set dollar limit that you or your employer pay to a health maintenance
organization (HMO), regardless of how much you use (or don't use) the services offered by the
health maintenance providers (ie, health professionals, doctors, hospitals)"
Case Management
"Case management is a system embraced by employers and insurance companies to ensure
that individuals receive appropriate, reasonable health care services."
Claim
A request by an individual (or his or her provider) to an individual's insurance company for the
insurance company to pay for services obtained from a health care professional.
Co-Insurance
"Co-insurance refers to money that an individual is required to pay for services, after a
deductible has been paid. In some health insurance plans, co-insurance is called
""co-payment"". Co-insurance is often specified by a percentage. For example, the employee
pays 20% toward the charges for a service and the employer or insurance company pays
80%."
Co-Payment
"Co-payment is a predetermined (flat) fee that an individual pays for health care services, in
addition to what the insurance covers. For example, some HMOs require a $10 ""co-payment""
for each office visit, regardless of the type or level of services provided during the visit.
Co-payments are not usually specified by percentages."
Deductible
"The amount an individual must pay for health care expenses before insurance (or a
self-insured company) covers the costs. Often, insurance plans are based on yearly
deductible amounts."
Denial of Claim
Refusal by an insurance company to honor a request by an individual (or his or her provider)
to pay for health care services obtained from a health care professional.
Employee Assistance Programs (EAPs)
"Mental health counseling services that are sometimes offered by insurance companies or
employers. Typically, individuals or employers do not have to directly pay for services
provided through an employee assistance program."
Exclusions
Medical services that are not covered by an individual's insurance policy.
Health Maintenance Organizations (HMO's )
"HMO's usually have excellent benefits (at reasonable premiums). Most of an individual's
health care is directed through a Primary Care Physician (PCP). Most HMO's do not require a
referral to OBGYN's, Dermatologists, or Mental Health Providers. Services in an HMO are
usually provided by physicians who are employed by, or under contract with, the HMO.
Depending on the type of HMO, services may be provided in a central facility, or in a
physician's own office. No benefits are available for out-of-network charges. Typically, you will
receive more benefits for your premium dollars in an HMO plan than other types of plans, due
to how the fees for services are paid."
Indemnity Health Plan
"Indemnity health insurance plans are also called ""fee-for-service"". These are the types of
plans that primarily existed before the rise of HMOs, POSs, and PPOs. With indemnity plans,
the individual pays a pre-determined percentage of the cost of health care services, and the
insurance company (or self-insured employer) pays the other percentage. For example, an
individual might may 20% for services and the insurance company pays 80%. The fees for
services are defined by the providers and vary from physician to physician. Indemnity health
plans offer individuals the freedom to choose their health care professionals."
Long-Term Care Policy
"Insurance policies that cover specified services for a specified period of time. Long-term care
policies (and their prices) vary significantly. Covered services often include nursing care, home
health care services, and custodial care."
LOS
"LOS refers to the length of stay. It is a term used by insurance companies, case managers
and/or employers to describe the amount of time an individual stays in a hospital or in-patient
facility."
Managed Care
"A medical delivery system that attempts to manage the quality and cost of medical services
that individuals receive. Most managed care systems offer HMOs and PPOs that individuals
are encouraged to use for their health care services. Some managed care plans attempt to
improve health quality, by emphasizing prevention of disease."
Maximum Dollar Limit
"The maximum amount of money that an insurance company (or self-insured company) will pay
for claims within a specific time period. Maximum dollar limits vary greatly. They may be based
on or specified in terms of types of illnesses or types of services. Sometimes they are
specified in terms of lifetime, sometimes for a year."
Medigap Insurance Policies
"Medigap insurance is offered by private insurance companies, not the government. It is not
the same as Medicare or Medicaid. These policies are designed to pay for some of the costs
that Medicare does not cover."
Out-Of-Plan
"This phrase usually refers to physicians, hospitals or other health care providers who are
considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an
individual's health insurance plan, expenses incurred by services provided by out-of-plan
health professionals may not be covered, or covered only in part by an individual's insurance
company."
Out-Of-Pocket Maximum
"A predetermined limited amount of money that an individual must pay out of their own savings,
before an insurance company or (self-insured employer) will pay 100% for an individual's
health care expenses."
Outpatient
"An individual (patient) who receives health care services (such as surgery) on an outpatient
basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance
companies have identified a list of tests and procedures (including surgery) that will not be
covered (paid for) unless they are performed on an outpatient basis. The term outpatient is
also used synonymously with ambulatory to describe health care facilities where procedures
are performed."
Point Of Service (POS)
"The POS plan is a hybrid HMO plan. With a POS plan, participants can elect whether to
receive treatment within the plan's managed HMO network, or go outside the network to
receive benefits. Simply put, a POS plan is an HMO plan with out-of-network benefits."
Pre-Admission Certification
"Also called pre-certification review, or pre-admission review. Approval by a case manager or
insurance company representative (usually a nurse) for a person to be admitted to a hospital
or in-patient facility, granted prior to the admittance. Pre-admission certification often must be
obtained by the individual. Sometimes, however, physicians will contact the appropriate
individual. The goal of pre-admission certification is to ensure that individuals are not exposed
to inappropriate health care services (services that are medically unnecessary)."
Pre-Admission Review
"A review of an individual's health care status or condition, prior to an individual being admitted
to an inpatient health care facility, such as a hospital. Pre-admission reviews are often
conducted by case managers or insurance company representatives (usually nurses) in
cooperation with the individual, his or her physician or health care provider, and
hospitals."
Pre-Admission Testing
Medical tests that are completed for an individual prior to being admitted to a hospital or
inpatient health care facility.
Pre-existing Conditions
"A medical condition that is excluded from coverage by an insurance company, because the
condition was believed to exist prior to the individual obtaining a policy from the particular
insurance company."
Preferred Provider Organizations (PPOs)
"PPO plans are usually the most expensive with the lowest benefit amount. The PPO plan has
in and out-of-network benefits. There is an array of PPO plans to choose from, such as higher
deductible and coinsurance plans, should there be a desire to lower the monthly premiums.
Generally, PPOs provide a larger network of Healthcare Providers than a HMO or POS. A
PPO plan does not require a Primary Care Physician (PCP) or referrals."
Primary Care Provider (PCP)
"A health care professional (usually a physician) who is responsible for monitoring an
individual's overall health care needs. Typically, a PCP serves as a ""quarterback"" for an
individual's medical care, referring the individual to more specialized physicians for specialist
care."
Provider
"Provider is a term used for health professionals who provide health care services.
Sometimes, the term refers only to physicians. Often, however, the term also refers to other
health care professionals such as hospitals, nurse practitioners, chiropractors, physical
therapist, and others offering specialized health care services."
Reasonable and Customary Fees
"The average fee charged by a particular type of health care practitioner within a geographic
area. The term is often used by medical plans as the amount of money they will approve for a
specific test or procedure. If the fees are higher than the approved amount, the individual
receiving the service is responsible for paying the difference. Sometimes, however, if
an individual questions his or her physician about the fee, the provider will reduce the charge
to the amount that the insurance company has defined as reasonable and customary."
Risk
"The chance of loss, the degree of probability of loss or the amount of possible loss to the
insuring company. For an individual, risk represents such probabilities as the likelihood of
surgical complications, medications' side effects, exposure to infection, or the chance of
suffering a medical problem because of a lifestyle or other choice. For example, an individual
increases his or her risk of getting cancer if he or she chooses to smoke cigarettes."
Second Opinion
"It is a medical opinion provided by a second physician or medical expert, when one physician
provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to
obtain second opinions whenever a physician recommends surgery or presents an individual
with a serious medical diagnosis."
Second Surgical Options
"These are now standard benefits in many health insurance plans It is an opinion provided by
a second physician, when one physician recommends surgery to an individual."
Short-Term Disability
An injury or illness that keeps a person from working for a short time. The definition of
short-term disability (and the time period over which coverage extends) differs among
insurance companies and employers. Short-term disability insurance coverage is designed to
protect an individual's full or partial wages during a time of injury or illness (that is not
work-related)
that would prohibit the individual from working.
Triple-Option
"Insurance plans that offer three options from which an individual may choose. Usually, the
three options are: traditional indemnity, an HMO, and a PPO."
"Usual, Customary, and Reasonable (UCR) or Covered Expenses"
"An amount customarily charged for or covered for similar services and supplies which are
medically necessary, recommended by a doctor, or required for treatment."
Waiting Period
A period of time when you are not covered by insurance for a particular problem.
Benefit
"Amount payable by the insurance company to a claimant, assignee, or beneficiary when the
insured suffers a loss."
Capitation
"Capitation represents a set dollar limit that you or your employer pay to a health maintenance
organization (HMO), regardless of how much you use (or don't use) the services offered by the
health maintenance providers (ie, health professionals, doctors, hospitals)"
Case Management
"Case management is a system embraced by employers and insurance companies to ensure
that individuals receive appropriate, reasonable health care services."
Claim
A request by an individual (or his or her provider) to an individual's insurance company for the
insurance company to pay for services obtained from a health care professional.
Co-Insurance
"Co-insurance refers to money that an individual is required to pay for services, after a
deductible has been paid. In some health insurance plans, co-insurance is called
""co-payment"". Co-insurance is often specified by a percentage. For example, the employee
pays 20% toward the charges for a service and the employer or insurance company pays
80%."
Co-Payment
"Co-payment is a predetermined (flat) fee that an individual pays for health care services, in
addition to what the insurance covers. For example, some HMOs require a $10 ""co-payment""
for each office visit, regardless of the type or level of services provided during the visit.
Co-payments are not usually specified by percentages."
Deductible
"The amount an individual must pay for health care expenses before insurance (or a
self-insured company) covers the costs. Often, insurance plans are based on yearly
deductible amounts."
Denial of Claim
Refusal by an insurance company to honor a request by an individual (or his or her provider)
to pay for health care services obtained from a health care professional.
Employee Assistance Programs (EAPs)
"Mental health counseling services that are sometimes offered by insurance companies or
employers. Typically, individuals or employers do not have to directly pay for services
provided through an employee assistance program."
Exclusions
Medical services that are not covered by an individual's insurance policy.
Health Maintenance Organizations (HMO's )
"HMO's usually have excellent benefits (at reasonable premiums). Most of an individual's
health care is directed through a Primary Care Physician (PCP). Most HMO's do not require a
referral to OBGYN's, Dermatologists, or Mental Health Providers. Services in an HMO are
usually provided by physicians who are employed by, or under contract with, the HMO.
Depending on the type of HMO, services may be provided in a central facility, or in a
physician's own office. No benefits are available for out-of-network charges. Typically, you will
receive more benefits for your premium dollars in an HMO plan than other types of plans, due
to how the fees for services are paid."
Indemnity Health Plan
"Indemnity health insurance plans are also called ""fee-for-service"". These are the types of
plans that primarily existed before the rise of HMOs, POSs, and PPOs. With indemnity plans,
the individual pays a pre-determined percentage of the cost of health care services, and the
insurance company (or self-insured employer) pays the other percentage. For example, an
individual might may 20% for services and the insurance company pays 80%. The fees for
services are defined by the providers and vary from physician to physician. Indemnity health
plans offer individuals the freedom to choose their health care professionals."
Long-Term Care Policy
"Insurance policies that cover specified services for a specified period of time. Long-term care
policies (and their prices) vary significantly. Covered services often include nursing care, home
health care services, and custodial care."
LOS
"LOS refers to the length of stay. It is a term used by insurance companies, case managers
and/or employers to describe the amount of time an individual stays in a hospital or in-patient
facility."
Managed Care
"A medical delivery system that attempts to manage the quality and cost of medical services
that individuals receive. Most managed care systems offer HMOs and PPOs that individuals
are encouraged to use for their health care services. Some managed care plans attempt to
improve health quality, by emphasizing prevention of disease."
Maximum Dollar Limit
"The maximum amount of money that an insurance company (or self-insured company) will pay
for claims within a specific time period. Maximum dollar limits vary greatly. They may be based
on or specified in terms of types of illnesses or types of services. Sometimes they are
specified in terms of lifetime, sometimes for a year."
Medigap Insurance Policies
"Medigap insurance is offered by private insurance companies, not the government. It is not
the same as Medicare or Medicaid. These policies are designed to pay for some of the costs
that Medicare does not cover."
Out-Of-Plan
"This phrase usually refers to physicians, hospitals or other health care providers who are
considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an
individual's health insurance plan, expenses incurred by services provided by out-of-plan
health professionals may not be covered, or covered only in part by an individual's insurance
company."
Out-Of-Pocket Maximum
"A predetermined limited amount of money that an individual must pay out of their own savings,
before an insurance company or (self-insured employer) will pay 100% for an individual's
health care expenses."
Outpatient
"An individual (patient) who receives health care services (such as surgery) on an outpatient
basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance
companies have identified a list of tests and procedures (including surgery) that will not be
covered (paid for) unless they are performed on an outpatient basis. The term outpatient is
also used synonymously with ambulatory to describe health care facilities where procedures
are performed."
Point Of Service (POS)
"The POS plan is a hybrid HMO plan. With a POS plan, participants can elect whether to
receive treatment within the plan's managed HMO network, or go outside the network to
receive benefits. Simply put, a POS plan is an HMO plan with out-of-network benefits."
Pre-Admission Certification
"Also called pre-certification review, or pre-admission review. Approval by a case manager or
insurance company representative (usually a nurse) for a person to be admitted to a hospital
or in-patient facility, granted prior to the admittance. Pre-admission certification often must be
obtained by the individual. Sometimes, however, physicians will contact the appropriate
individual. The goal of pre-admission certification is to ensure that individuals are not exposed
to inappropriate health care services (services that are medically unnecessary)."
Pre-Admission Review
"A review of an individual's health care status or condition, prior to an individual being admitted
to an inpatient health care facility, such as a hospital. Pre-admission reviews are often
conducted by case managers or insurance company representatives (usually nurses) in
cooperation with the individual, his or her physician or health care provider, and
hospitals."
Pre-Admission Testing
Medical tests that are completed for an individual prior to being admitted to a hospital or
inpatient health care facility.
Pre-existing Conditions
"A medical condition that is excluded from coverage by an insurance company, because the
condition was believed to exist prior to the individual obtaining a policy from the particular
insurance company."
Preferred Provider Organizations (PPOs)
"PPO plans are usually the most expensive with the lowest benefit amount. The PPO plan has
in and out-of-network benefits. There is an array of PPO plans to choose from, such as higher
deductible and coinsurance plans, should there be a desire to lower the monthly premiums.
Generally, PPOs provide a larger network of Healthcare Providers than a HMO or POS. A
PPO plan does not require a Primary Care Physician (PCP) or referrals."
Primary Care Provider (PCP)
"A health care professional (usually a physician) who is responsible for monitoring an
individual's overall health care needs. Typically, a PCP serves as a ""quarterback"" for an
individual's medical care, referring the individual to more specialized physicians for specialist
care."
Provider
"Provider is a term used for health professionals who provide health care services.
Sometimes, the term refers only to physicians. Often, however, the term also refers to other
health care professionals such as hospitals, nurse practitioners, chiropractors, physical
therapist, and others offering specialized health care services."
Reasonable and Customary Fees
"The average fee charged by a particular type of health care practitioner within a geographic
area. The term is often used by medical plans as the amount of money they will approve for a
specific test or procedure. If the fees are higher than the approved amount, the individual
receiving the service is responsible for paying the difference. Sometimes, however, if
an individual questions his or her physician about the fee, the provider will reduce the charge
to the amount that the insurance company has defined as reasonable and customary."
Risk
"The chance of loss, the degree of probability of loss or the amount of possible loss to the
insuring company. For an individual, risk represents such probabilities as the likelihood of
surgical complications, medications' side effects, exposure to infection, or the chance of
suffering a medical problem because of a lifestyle or other choice. For example, an individual
increases his or her risk of getting cancer if he or she chooses to smoke cigarettes."
Second Opinion
"It is a medical opinion provided by a second physician or medical expert, when one physician
provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to
obtain second opinions whenever a physician recommends surgery or presents an individual
with a serious medical diagnosis."
Second Surgical Options
"These are now standard benefits in many health insurance plans It is an opinion provided by
a second physician, when one physician recommends surgery to an individual."
Short-Term Disability
An injury or illness that keeps a person from working for a short time. The definition of
short-term disability (and the time period over which coverage extends) differs among
insurance companies and employers. Short-term disability insurance coverage is designed to
protect an individual's full or partial wages during a time of injury or illness (that is not
work-related)
that would prohibit the individual from working.
Triple-Option
"Insurance plans that offer three options from which an individual may choose. Usually, the
three options are: traditional indemnity, an HMO, and a PPO."
"Usual, Customary, and Reasonable (UCR) or Covered Expenses"
"An amount customarily charged for or covered for similar services and supplies which are
medically necessary, recommended by a doctor, or required for treatment."
Waiting Period
A period of time when you are not covered by insurance for a particular problem.
Our glossary is a continued effort. If you are looking for a definition and do not
find it here, please email us and will email you the definition and post it on our
site. Thank you for your help!
find it here, please email us and will email you the definition and post it on our
site. Thank you for your help!
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762 Lemay Ferry
St. Louis, Missouri 63125
314-638-5020 Office
314-638-7731 Fax
info@parkerinsurancegroup.com
St. Louis, Missouri 63125
314-638-5020 Office
314-638-7731 Fax
info@parkerinsurancegroup.com
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| Large enough to serve you, Small enough to care! |
With offices in St
Louis, Florissant, St.
Charles, Fenton and
Leslie, Parker
Insurance Group is
proud to serve the
entire states of
Missouri and Illinois.
Louis, Florissant, St.
Charles, Fenton and
Leslie, Parker
Insurance Group is
proud to serve the
entire states of
Missouri and Illinois.