Health Insurance Guide
No matter what insurance you plan on getting it is always best to know something about it. It is no different for Health Insurance. Health Insurance in the United States is a must failing which you will not be able to get or afford medical care. When you purchase a health insurance make sure that you know the terms that are used in the policy so that you know what you are entitled to and also the limitations if any.
Here are some of the common terms used in Health Insurance:
Access: It means a person’s ability to get affordable medical care on timely basis.
Accreditation: An evaluative process where a health care organization is checked for its operational procedures to see if they meet the designated criteria defined by the accrediting body and to ensure that the organization meets a specified level of quality.
Actuaries: Insurance professionals who set insurance premium rates.
Ancillary services: Supplemental services such as diagnostic services, home health services, physical therapy and occupational therapy used to support diagnosis and treatment of a patients condition.
Appropriate care: A treatment where expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.
Children's Health Insurance Program (CHIP): A program, established by the Balanced Budget Act, designed to provide health help to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.
Claim: A statement of healthcare services and their costs provided by the hospital, physician or other provider facility. Claims are submitted to the insurer for payment of costs.
Claim form: An application for payment of benefits under a health plan.
Claimant: The person submitting the claim.
Claims administration: The process of receiving, reviewing, adjudicating and processing the claims.
Claims investigation: Process of obtaining all the information necessary to determine the amount to pay on a given claim.
Closed access: Provision which specifies that plan members must obtain medical services only from network providers through a primary care physician to receive benefits.
Coinsurance: A method of cost sharing in a health insurance policy that requires a member to pay a stated percentage of medical expenses.
Compensation committee: Board of directors that sets compensation guidelines for a managed care plan.
Deductible: A flat amount a group member has to pay before the insurer will make any benefit payment.
Disease management: A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost effective, quality healthcare for a patient population who are at risk for a chronic medical condition.
Drive time: A measure of time when members of the plan’s service area have to drive to reach a primary care provider.
Fully Funded Plan: Health plan which an insurer or MCO bears the financial responsibility of guaranteeing payments and paying for benefits and administrative costs.
Grievances: Formal complaints demanding formal resolution.
Health care quality: The degree to which health services for individuals and people increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Insured: The usual term for a person who purchases insurance for themselves. The insured could also be a close family member of the purchaser.
Lifetime Maximum Benefit amount: The maximum payment set by an MCO that limits the total amount the plan must pay for all healthcare services provide during the subscriber’s lifetime.
Out of pocket maximums: Amounts set by MCOs that limit the amount a member has to pay out of is pocket for a particular healthcare service.
Policy: This is the term for a contract between an insurance company and a purchaser of life insurance
Premium: A prepaid payment or series of payments made to a health plan by purchasers, and plan members, for medical benefits.
Premium taxes: State income taxes levied on an insurer's premium income.
Primary care: General medical care that is provided directly to a patient without referral from another physician. It is focused on preventative care and the treatment of routine injuries and illnesses.
Termination provision: A provider contract clause that describes how and under what circumstances the parties may end the contract.