Health Insurance Terminology
The definitions appearing in this Glossary are provided solely for general informational purposes. They are not intended to be complete descriptions of all terms, conditions and exclusions applicable to the products and services defined. Also, in the case of any inconsistency between the definitions in this Glossary and the definitions appearing in the actual insurance policy, the definitions contained in the actual policy shall govern.
Actuary An insurance mathematician who calculates rates, statistics, and reserves.
Agent A qualified representative of one or more insurance companies licensed to sell insurance.
Benefit The amount an insurance company pays to a policyholder when a loss occurs.
Brand-Name Prescription Drug Drugs developed, manufactured, and marketed with a brand name by a pharmaceutical company. Brand name drugs are typically more expensive that generic drugs.
Broker An insurance salesperson that searches for quotes and plan options for individual clients.
Carrier A company that provides insurance plans.
Case Management A management system in which case managers monitor patients’ health care, to improve quality, reduce cost, and ensure the patient receives appropriate care.
Claim A request to an insurance company for payment of a service received.
COBRA (Consolidated Omnibus Budget Reconciliation Act) Legislation allowing employees to keep their group health coverage temporarily after they leave the job.
Coinsurance A portion of a single medical bill, expressed in a percentage, the insured is responsible for paying.
Copayment A portion of a single medical bill, expressed in a dollar amount, the insured is responsible for paying.
Deductible The yearly amount an insured must pay out-of-pocket before insurance coverage begins.
Dependents Any person directly financially relying on insured. Usually includes spouse and unmarried children.
Effective Date The date when insurance coverage begins.
Exclusions Any medical or health care services not covered by an insurance plan.
Fee For Service (FFS) Plan Also known as traditional “indemnity” coverage, FFS plans reimburse policyholders for the care they receive, as long as it’s covered, from any health care provider.
Flexible Spending Account (FSA) A savings account in which income can be deposited tax-free for health care expenses. At the end of the year, any unused funds in an FSA are forfeited.
Formulary The list of all covered prescription drugs.
Generic Drug Duplicates of brand-name drugs made after the patent expires of the company who developed the drug. Typically, generic drugs are much less expensive than brand-name drugs. And they’re just as safe and effective.
Group Insurance Health insurance coverage offered for employees of a business.
Guaranteed Issue Law, varying by state, requiring all insurance applicants to be accepted regardless of health condition, health history, age, or any other factor.
Health Insurance Quote Health plan options provided by an automated quoting service, an agent, or an insurance company.
Health Maintenance Organization (HMO) A managed care plan in which members must receive care from the network of doctors, hospitals, and other care providers. They must also choose a Primary Care Physician (PCP) from the network to be their “first-line-of-defense” doctor, and to provide referrals to specialist care.
Health Reimbursement Arrangement A designated amount of money determined by an employer to spend on their employees’ health care expenses.
Health Savings Account (HSA) A bank account where tax-free income can be saved for health care expenses. Each year unused HSA funds grow in interest. To be eligible to open an HSA, you must first enroll in a high-deductible health plan.
High-Deductible Health Plan (HDHP) Plans with a deductible of at least $1,100 for individuals ($2,200 for families). Enrollment in an HDHP makes you eligible to open a Health Savings Account (HSA).
HIPAA (Health Insurance Portability and Accountability Act) Legislation that allows people to change jobs and be accepted into their new company’s group health insurance plan regardless of pre-existing conditions or health history.
Individual Retirement Account (IRA) An account to save money for retirement. Funds from an IRA can be moved to a Health Savings Account (HSA).
In-Network Care Providers Any health care professional that agrees with a health plan to discount their medical services in exchange for patient referrals.
Inpatient Care Care in which patients must stay overnight in a medical facility.
Insurability The factors that determine if an applicant will be accepted into a health plan, including age, health history, and current health conditions.
Long-Term Care Care intended to nurse a patient back to health over an extended period of time. Can include unskilled care, skilled nursing care, and custodial care.
Major Medical Insurance Insurance that provides coverage for major and catastrophic medical care.
Managed Care A type of health insurance that creates an agreement with a “network” of doctors, hospitals, and other care providers. The health plan provides patient referrals in exchange for discounted medical services.
Maximum Dollar Limit The maximum dollar amount of benefits and claims that an insurance company will pay in a certain period of time.
Maximum Lifetime Benefit The maximum dollar amount of benefits and claims an insurance company will pay in the insured’s lifetime.
Medicaid A government-sponsored program that provides health care for low-income Americans.
Medicare A government-sponsored program that provides health care for Americans over the age of 65 and those with end-stage renal disease.
Medicare Advantage Plans These plans provide Medicare benefits that can be purchased and received through private companies. They can also include prescription drug coverage.
Medicare Supplement (Medigap) Insurance Plans Extra insurance coverage purchased through private insurance companies to cover some of the health care costs regular Medicare does not.
Mutual Insurance Company Insurance companies that have no public stock and are owned by the wholly by the policyholders.
Network The group of doctors, physicians, hospitals, clinics, and specialists that agree with a health plan to discount their medical services in exchange for patient referrals.
Out-Of-Pocket Maximum The maximum amount of health care costs that an insured must pay out of their own pocket per year. After the out-of-pocket max is met, the plan will cover 100% of any remaining costs for the year.
Outpatient Care Care that does not require a patient to stay overnight in a medical facility.
Point of Service (POS) Plan A managed care plan that combines the benefits of a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). Like an HMO, POS plans require members choose a Primary Care Physician (PCP). Like a PPO, they provide coverage with any in or out-of-network health care providers.
Pre-Admission Review and Certification Approval by a health care professional to be admitted into a medical facility.
Pre-Existing Conditions Any health condition before coverage starts can be considered a pre-exiting condition. Insurance companies may require a waiting period before they cover costs related to that condition.
Preferred Provider Organizations (PPO) A managed care plan in which members have insurance coverage with in and out-of-network doctors, hospitals, and other health care providers. Typically, members save the most on care with in-network providers.
Premium The payment that must be made to an insurance company monthly to keep a health insurance policy in effect.
Preventive Care Health care intended to prevent serious (or more serious) illness through routine doctor’s check-ups, physicals, well-baby care, and immunizations.
Primary Care Physician (PCP) Can include family doctors, pediatricians, internists, general practitioners, and OB/GYNs. Members of a Health Maintenance Organization (HMO) or Point of Service (POS) plan choose a PCP as their “first-line-of-defense” doctor. They also can provide referrals for specialist care.
Provider Includes doctors, physicians, hospitals, clinics, specialists, or any health care professional.
Rider An addition or exclusion included on an insurance policy.
Risk An insurance company’s chance of loss. Also refers to the chance of an individual becoming ill or having an accident.
Short-Term Disability An illness or injury that prevents an employee from working for a period of time.
Short-Term Medical Insurance An insurance plan that provides insurance coverage for a designated period of time — usually between one month and one year. Many individuals who purchase short-term coverage include recent college graduates and people in-between jobs.
Travel Insurance Health plans that provide coverage for people while during a trip to another country.
Underwriter An insurance professional that determines the premiums for applicants.
Underwriting The process in which an insurance company or underwriter determines the amount the premiums will be for applicants.
Usual, Customary, and Reasonable Fees The standard amount that is usually covered or charged for medical services and supplies, as recommended by health care professionals.
Utilization Review The process in which the care of patients are monitored for cost-effectiveness, efficiency, and quality.
Waiting Period Also known as the elimination period, it refers to the temporary amount of time an insured will not be covered for certain health care costs.
Waiver of Premium An additional insurance policy that can be purchased. It waives premiums for a period of time if the insured becomes totally disabled and cannot make monthly payments.