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Agent (Also referred to as a Broker or a Producer): A legally licensed person who represents and negotiates with an insurance company on the behalf of the policyholder. Brokers receive a commission from the insurance company.
Ambulatory Care: Health services that don’t require an overnight hospital stay.
Ancillary Services: Services related to a patient’s care, other than those provided by a doctor or hospital; i.e.: lab work, x-rays or anesthesia.
Beneficiary:A person eligible for benefit under a health insurance policy.
Benefit Cap: The total amount that a payer will reimburse for covered healthcare services during a specified period, such as one year.
Broker (Also referred to as an Agent or a Producer): A legally licensed person who represents and negotiates with an insurance company on the behalf of the policyholder. Brokers receive a commission from the insurance company.
Care Plan: A written plan for one’s healthcare.
COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985, which is commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for employees and their dependents, usually for 18 months after the employee leaves the job.
Coinsurance: Coinsurance is a cost-sharing arrangement in which the insured is required to pay a percentage of covered healthcare expenses incurred, typically after meeting a deductible.
Copayment: A copayment (co-pay) is a set amount that you pay for a specific service, such as $25 for an office visit. You are usually responsible for payment at the time of service.
Comprehensive plan: A comprehensive plan provides coverage for most medical services – usually after a deductible has been met – using a reimbursement formula.
Current Procedural Terminology (CPT): A terminology and coding system developed by the American Medical Association (AMA) to describe, code and report healthcare services or procedures.
Deductible: A deductible is the amount paid by an insured person, usually each calendar year, before health insurance benefits are paid for covered medical expenses.
Discharge Planning: Development by hospital staff and attending physician of a care plan prior to a patient’s discharge.
Enrollee: The person who is the primary insured.
Exclusion Period: A period of time an insurance company may delay coverage of a pre-existing condition.
Formulary: A list of certain drugs and dosages, for which most health plans provide better benefits than for non-formulary drugs.
Health Maintenance Organization (HMO): A managed care plan that requires the participant to use only contracted physicians and hospitals to receive benefit care. Typically, the participant needs to be referred by their primary care doctor to see a specialist.
Health Savings Account (HSA): A Health Savings Account (HSA) is an account that works like an Individual Retirement Account (IRA), except the money saved is earmarked for future health care costs. Anyone who buys a qualified high deductible health plan (one that meets the requirements the government has determined), with at least a $1,000 single or $2,000 family deductible, qualifies for an HSA. The money you deposit into your Health Savings Account, as well as the earnings, is tax-deferred. You can withdraw money at any time to pay for qualified medical expenses, without being penalized. You can even roll over unused balances from year to year.
HIPPA (Health Insurance Portability & Accountability Act:) A law passed in 1996, which expanded healthcare coverage for persons who lose or change their job, to make it possible for persons with pre-existing medical conditions to get health insurance coverage.
Hospice: Hospice care is that which is provided for the terminally ill, and their families.
Indemnity health insurance plan: An indemnity plan, also called a traditional or fee-for-service health insurance plan, is one which allows freedom to choose any doctor or hospital for care, so there is no penalty for choosing a particular doctor or hospital. Instead, the plan pays a percentage of the service costs, which often results in higher premiums than for PPO plans.
Inpatient care: Overnight hospital health care.
Lifetime Maximum: A cap on benefits paid for the duration of an insurance policy.
Managed Care: A method managing the costs, use and quality of healthcare service (see HMO or PPO).
Mandate: As it refers to healthcare, a mandate is a requirement that an insurance company or health plan cover (or offer coverage for) certain healthcare providers, benefits and patient populations. For example, Washington State requires that coverage for procedures such as mammograms, providers including chiropractors and populations such as non-custodial children be provided.
Medicaid: Federal and state health insurance program for low-income individuals.
Medicare: A Federal program that provides healthcare coverage for the elderly (age 65 and older), certain disabled individuals and those with end-stage renal disease.
Medigap: A supplemental insurance policy to help cover the difference between approved medical charges and benefits paid by Medicare.
Noncancellable Policy: A policy that guarantees insurance coverage, as long as the insured pays the premium.
Out-Of-Network: Healthcare services received outside an HMO or PPO provider network.
Pre-existing Condition: A health-related issue that exists before the date an insurance policy is in effect.
Preferred Provider Organization (PPO): A PPO is a large network of contracted doctors and hospitals (“providers”) who agree to grant services to plan participants at a discounted rate, often with reduced premiums and/or out-of-pocket costs.
Producer (Also referred to as an Agent or Broker): A legally licensed person who represents and negotiates with an insurance company on the behalf of the policyholder. Brokers receive a commission from the insurance company.
Provider: A doctor, hospital, lab, nurse or other who delivers medical or health-related care.
Qualifying Event: Most frequently used in reference to COBRA eligibility, a qualifying event is an occurrence (e.g.: termination of employment, divorce or death) that changes an employee's eligibility status under a group health plan.
Renewal: A continuation of insurance coverage with revised terms.
Rider: An attachment, amendment or endorsement to an insurance policy.
Risk: A risk is the possibility an insurance company presumes when it covers groups’ claims, that the cost of claims will exceed their expected level, with subsequent financial loss. Insurance companies use it to determine whether they will underwrite an insurance policy on a particular group.
Self-insured: Regulated by the Employee Retirement Income Security Act of 1974, a self-insured employer is one who assumes risk for healthcare expenses in a plan that is self-administered or administered by a third party administrator (TPA.)
Service Area: A designated area in which a health plan will accept members.
Supplement Plan (Medicare): A Supplement Plan (sometimes called Medigap Plan) is one that provides benefits for services that Medicare may not cover. Though Supplement Plans don’t have a network of preferred providers, they often are most costly.
Underwriting: The evaluation and review of prospective insured individuals for risk assessment and appropriate insurance premium.
Waiting Period: A period of time when the healthcare benefit plan does not cover an individual for a particular health problem, usually due to a preexisting condition.
inova | 1206 N. Lincoln Suite 200 | Spokane WA 99201-2559 | P: 509.777.2655 TF: 866.696.3154
Fx: 509.777.2675 | E: jskeesick@aiin.net
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