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Industry Glossary

A

An organization, made up of a network of healthcare providers that coordinate patient care and provide the full range of healthcare services for patients. Accumulation Period: A specified period during which a covered employee must accumulate eligible expenses to meet the plan’s deductible amount.
The percentage of benefit costs the health insurer expects to pay toward a health plan.  It is based on an average for a population or area, and may not necessarily reflect actual cost sharing
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
A request for your health insurer or plan to review a decision or a grievance again.

B

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

C

 A corporate benefits plan where employees are permitted to choose among two or more benefits that consist of cash and certain qualified benefits. Cafeteria plans are also called flexible benefit plans, Flex plans or Section 125.
A plan on a calendar year runs from January 1 – December 31. Items like deductible, maximum out-of-pocket expense, etc. will reset every January 1.
Provision in major medical plans to avoid two deductibles applied to covered medical expenses when expenses are incurred toward the end of one calendar year and sickness or injury continues into the next year.
A health plan with limited benefits, a high deductible, and a generally lower premium.  Available to persons under 30, it provides coverage for unforeseen and expensive illness or injuries.
Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA permits eligible employees and beneficiaries to continue their health coverage for a period of time after it would normally terminate. The continuation of coverage requires the individual to pay a premium.  COBRA applies to groups of 20 or more people.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
A plan on a contract year (also called benefit year) runs for any 12-month period within the year. Items like deductible, maximum out-of-pocket expense, etc. will reset at the plan’s renewal date. For example, ABC Company renews on July 1 every year. The deductible would start July 1 and end on June 30. The deductible would reset every July 1 for ABC Company members.
A process if an individual has two group health plans, the amount payable is divided between the plans so that the combined coverage amounts to, but does not exceed, 100 percent of the charges.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Stands for Current Procedural Terminology code and was designed by the American Medical Association as a method to communicate, by a five-digit number, specific medical care, and services. The numbering system covers the majority of recognized medical services a physician can provide and be reimbursed. The CPT code is used to report services on the claim form.

D

For persons with chronic conditions (diabetes, COPD, etc.) it is the coordination of care for the entire disease treatment process, including patient education, inpatient and outpatient care, preventive care, and acute care.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

E

Employers with 51 or more employees must offer affordable coverage to its full-time employees or pay a penalty.
An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
A set of 10 benefits including ambulatory patient services, emergency services, maternity and newborn care, hospitalization, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, laboratory services, pediatric services, and preventive care that must be included in a qualified health plan (QHP) for individuals and small groups.
General term for the online marketplace all states are required to have for individuals and small businesses. They serve as an Expedia or Orbitz for the health insurance market, where private insurers can offer health plans.  See also Health Insurance Marketplace and Small Business Health Options Program.

F

A list of prescription drugs covered by a prescription drug plan offering prescription drug benefits. Also called a drug list.
A tax-advantaged financial account that can be set up through a cafeteria plan of an employer that allows an employee to set aside a portion of earnings to pay for qualified medical expenses as established in the cafeteria plan. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes.

G

A complaint that you communicate to your health insurer or plan.
A tax-advantaged financial account that can be set up through a cafeteria plan of an employer that allows an employee to set aside a portion of earnings to pay for qualified medical expenses as established in the cafeteria plan. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes.

H

 A tax-advantaged medical savings account available to taxpayers enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit.
A tax-advantaged financial account that can be set up through a cafeteria plan of an employer that allows an employee to set aside a portion of earnings to pay for qualified medical expenses as established in the cafeteria plan. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Care in a hospital that usually doesn’t require an overnight stay.

I

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

M

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Program administered by the state’s Department of Medical Assistance Services (DMAS) under The Centers for Medicare and Medicaid Services (CMS). Payments are made for approved healthcare services provided by hospitals, health agencies, and private practitioners for welfare recipients or persons whose income does not exceed maximum limits. Funds are derived on a state-federal shared basis.
A term used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with the standards of good medical practice and the medical community.
Program administered by the state’s Department of Medical Assistance Services (DMAS) under The Centers for Medicare and Medicaid Services (CMS). Payments are made for approved healthcare services provided by hospitals, health agencies, and private practitioners for welfare recipients or persons whose income does not exceed maximum limits. Funds are derived on a state-federal shared basis.
The federally financed hospital insurance system (part A) and supplementary medical insurance (Part B) for the aged created by the 1965 amendment to the Social Security Act.
A person eligible to receive, or receiving, benefits from an HMO or insurance policy. Includes both those who have enrolled or “subscribed,” and their eligible dependents.

N

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

O

The period (usually once a year) during which subscribers in a health plan may have an opportunity to select an alternative plan being offered to them; or a period when uninsured employees and their dependents may obtain coverage.
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out- of-network co-insurance usually costs you more than in- network co-insurance.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

P

A law with a series of statues that go into effect beginning March 23, 2010 aimed at increasing access to affordable healthcare for most Americans.  Health insurers, healthcare facilities, physicians, individuals, small and large businesses, Medicare, and Medicaid are all impacted by the law.
A health condition (except pregnancy) that was diagnosed and/or treated within six months prior to enrolling in a health plan.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
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 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.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

R

Insurance obtained by a carrier from another company to protect itself against part or all the losses incurred in the process of honoring the claims of members or policyholders. Also referred to as “stop loss” insurance. The coverage may apply to an individual claim or to all claims during a specified period for an individual enrollee.
A financial arrangement that spreads the risk of utilization and cost among the participants generally the insurer, the hospitals, and the physicians. The pool may insure against unusually high utilization and costs. The pool may also provide incentives for controlling utilization and costs.
Deductibles paid under a previous plan that are applied to the deductibles of the current plan.

S

A completely non-insured or self-funded plan is one in which no insurance company or insurance plan collect premiums and assumes financial risk.  Employer groups use self-funded plans where they collect premiums from employees and pay the claims, but contract with an insurer to provide the administrative services.
The portion of the Exchange dedicated to small businesses with 2-50 employees. Businesses with 51-100 employees will be eligible to participate in the SHOP beginning January 1, 2016.

T

An organization that administers healthcare benefits, mostly for self-insured employers. Services may include claims review and claims processing.

U

The maximum amount an insurer will consider eligible for reimbursement under group health insurance plans. Charges are generally based on customary fees paid to providers with similar training and experience in a given geographic area.

V

Voluntary worksite benefits are one of the best ways to attract and retain high-quality employees in a competitive labor market. These are solutions that help employees in numerous ways, with very little (and in many cases zero) cost to the employer.

There are several types of voluntary worksite benefits than employers can offer, these include:

  • Accident insurance
  • Cancer insurance
  • Critical illness insurance
  • Hospital indemnity
  • Identity theft insurance
  • Legal services
  • Pet insurance
  • Retail discounts
  • Concierge services