Health Insurance Glossary and Definitions
Access: A person's ability to obtain affordable medical care in a timely manner.
Actuary: A business professional who analyzes the financial consequences of risk.
Actuaries use mathematics, statistics, and financial theory to study uncertain future events, especially those of concern to insurance and pension programs.
Their job is to make sure a block of business is priced to be profitable.
Admitting Privileges: The right granted to a doctor to admit patients to a particular hospital.
Agent: A licensed salesperson who represents one or more health insurance companies and presents their products to consumers.
In order to sell insurance in any particular state, the agent must be licensed in that state.
Aggregate Stop-Loss Coverage: A type of stop-loss insurance that provides benefits when a group's total claims during a specified period exceed a stated amount.
Allowable Fee: The maximum amount a health insurer will pay for a service or procedure.
Ambulatory Care Facility (ACF): A medical clinic or medical center that provides a wide range of healthcare services, including surgery, preventive, outpatient, and acute care in a centralized facility.
Ancillary Services: Supplemental services such as diagnostic and home health services, physical and occupational therapy, used to support diagnosis and treatment of a patient's condition.
Arbitration A process in which all parties in a dispute submit their dispute to an impartial third party for a final, binding decision.
Archer Medical Savings Accounts: Individual accounts that may be set up by self-employed individuals and those who work for small companies. Funds in the accounts are used to pay medical expenses.
Assignment: The legal transfer of one person's interest in an insurance policy to another person.
Association: A group, such as AARP. Often, associations can offer individual health insurance plans specially designed for their members.
Autonomy: An ethical principle which, when applied to managed care, states that health care companies and their providers have a duty to respect the right of their members to make decisions about the course of their lives.
Balance Billing: A billing practice in which you are billed for the difference between what your insurer pays and the fee that the provider normally charges.
Behavioral Healthcare: Mental health and chemical dependency (or substance abuse) services.
Beneficence: The ethical principle that requires providers, other things being equal, to do what will further the patient's interest.
Benefit: Amount payable by the insurance company when the insured suffers a loss or incurs a covered cost.
Blended Rating: For groups with limited recorded claim experience, a method of forecasting a group's cost of benefits based partly on a managed care organization's manual rates and partly on the group's experience.
Brand-Name Drug: Prescription drugs marketed with a specific brand name by the company that manufactured it - usually the company that developed it.
These drugs are patented by that company and, until the patent expires, these drugs cannot be manufactured by any other company. After patent expiration, other
companies can manufacture these drugs, called generics, and the cost is usually much lower than the original, brand-name version.
Broker: A licensed insurance agent who obtains quotes, rates, and plans from multiple companies for thier clients.
Capitation: 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.
Captive Agents: Agents that represent only one health plan or insurer.
Carve-Out: The separation of a medical service (or a group of services) from the basic set of benefits in some way.
Carrier: The insurance company or HMO offering a health plan.
Categorically Needy Individuals Individuals who receive Medicaid benefits because of their welfare status.
CCPs: See coordinated care plans.
Certificate of Insurance: The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what it covered, what is not, and dollar limits.
Chronic: One or more medical conditions that persist for long periods of time or for the patient's lifetime.
Claim: An itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other provider facility.
Claim Form: An application for payment of benefits under a health plan.
Claims Examiners: Employees in the claims administration department who consider all the information pertinent to a claim and make decisions about the payment of the claim. Also known as claims analysts.
COBRA: Consolidated Omnibus Budget Reconciliation Act. A federal act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period
of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee, and termination of employment.
Coding Errors: Documentation errors where a treatment is miscoded or the codes used to describe procedures do not match those used to identify the diagnosis.
Coinsurance: The amount you must pay for medical care after you have met your deductible. Typically, your plan will pay 80 percent of an approved amount, and your coinsurance will be 20 percent, but this may vary from plan to plan.
Competitive Medical Plan (CMP): A federal designation that allows managed care organizations to enter into Medicare risk contracts without having to obtain federal qualification as an HMO.
Copay: The flat fee you pay each time you receive medical care from a a participating provider in your health care plan.
Covered Expenses: See Usual, Customary and Reasonable Fees.
Credentialing: The review and verification process used to determine the current clinical competence of a provider and whether the provider meets the managed care organization's pre-established criteria for participation in their network.
Credit for Prior Coverage: This may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer's (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines.
Cure Provision: A provider contract clause which specifies a time period (usually 60-90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.
Deductible: The amount you must pay each year before your plan begins paying.
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.
Dependents: Spouse and/or unmarried children (whether natural, adopted or step) of an insured. Different providers have different rules, such as age of children, whether they
are full-time students, etc.
Disability Insurance: Pays benefits if you are injured or become seriously ill and are no longer able to work.
Discharge Planning: A process used to help determine what activities must occur before a patient is ready for discharge from a hospital or care facility and the most efficient way to conduct those activities.
Disease Management: A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at
risk for a specific chronic illness or medical condition.
Dual Eligibles: Elderly and disabled Medicaid recipients who also qualify for Medicare coverage.
Due Process Clause: A provider contract provision which gives providers that are terminated with cause the right to appeal the termination.
Effective Date: The date your insurance is to actually begin. You are not covered until the policies effective date.
Employee Assistance Programs: Mental health counseling services that are sometimes offered by insurance companies or employers.
Employee Benefits Consultant: A specialist in employee benefits and insurance who is hired by a group buyer to provide advice on a health plan purchase.
EMR: Electronic Medical Record.
Encounter: A term used to describe a healthcare visit of any type by an enrollee to a provider of heath care or services.
EPO: Exclusive Provider Organization. A healthcare benefit arrangement similar to a PPO in administration, structure, and operation, but which does not cover out-of-network care.
ERISA: Employee Retirement Income Security Act.
Ethics in Patient Referrals Act: A federal act which, along with its amendments, prohibits a physician from referring patients to laboratories, radiology services, diagnostic services, physical therapy
services, home health services, pharmacies, occupational therapy services, and suppliers of durable medical equipment in which the physician has a financial interest. Also known as the Stark Laws.
Exclusions: Services that are not covered by a plan. Sometimes called limitations. These exclusions and limitations must be clearly spelled out in plan literature.
Exclusive Remedy Doctrine: A rule which states that employees who are injured on the job are entitled to workers' compensation benefits, but they cannot sue their employers for additional amounts.
Explanation of Benefits: The insurance company's written explanation regarding the payment of a claim, showing what they paid and what the insured must pay.
If all or part of the claim was denied, it will also explain the reason for the denial.
Federal Employee Health Benefits Program: (FEHBP). A voluntary health insurance program for federal employees, retirees, and their dependents and survivors.
Fee-For-Service Insurance: Traditional (indemnity) health insurance where you and your plan each pay a portion of your health expenses, usually after you meet a yearly deductible. In most cases, you can choose any physician, hospital, or other provider (non-network based coverage).
FFS: Fee For Service.
Fee Schedule: The fee determined by an managed care organization to be acceptable for a service and which the care provider agrees to accept as payment in full. Also known as a fee allowance, fee maximum, or capped fee.
Flexible Spending Arrangements: Employees use pre-tax dollars to set up these accounts and draw down on them to pay qualified medical expenses during the year. Unused amounts are forfeited at the end of the year.
Formulary: An insurance company's list of covered drugs.
Fully Funded Plan: A health plan under which all costs are paid for by the provider, with no co-pays or deductibles.
Generic Drug: Once the patent has run out on the brand name drug, other drug companies are allowed to sell a duplicate of the original, which is called a generic. Generic drugs are cheaper, and most prescription
and health plans reward clients for choosing generics. They are identical to the original drug other than their name and price.
Geographic Availability: The number of primary care providers within a given radius of a target area.
Group Insurance: Health plans offered to a group of individuals by an employer, association, union, or other entity. With group insurance,
all individuals in that group are covered.
Group Market: A market segment that includes two or more people who enter into a group contract with an managed care organization under
which the MCO provides healthcare coverage to all members of that group.
Health Care Quality Improvement Act (HCQIA): A federal act which exempts hospitals, group practices, and HMOs from certain antitrust provisions as they apply to credentialing and peer review so long as these
entities adhere to due process standards that are outlined in the Act.
Health Insurance Portability and Accountability Act (HIPAA): A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies, and managed care organizations must
satisfy in order to provide health insurance coverage in the individual and group healthcare markets.
Health Reimbursement Arrangement: An account established by an employer to pay an employee's medical expenses. Only the employer can contribute to a health reimbursement account.
Health Risk Assessment (HRA): A process by which an MCO uses information about a plan member's health status, personal and family health history, and health-related behaviors to predict the member's likelihood of experiencing
specific illnesses or injuries. Also known as health risk appraisal.
Healthcare Quality: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
High-Deductible Health Plan: A plan that provides comprehensive coverage for high-cost medical events. It features a high deductible and a limit on annual out-of-pocket expenses. This type of plan is usually coupled with a health savings account or a health spending account.
High-Risk Case: A patient who has a complex or catastrophic illness or injury or who requires extensive medical interventions or treatment plans.
High-Risk Pool: A State-operated program that offers coverage for individuals who cannot get health insurance from another source due to serious illness.
HMO: Health Maintenance Organization. A form of managed care in which you receive all of your care from participating providers. You usually must obtain a referral from your primary care physician before you can see a specialist.
Hold Harmless Provision: A contract clause which forbids providers from seeking compensation from patients if the health plan fails to compensate the providers because of insolvency or for any other reason.
Hospice Care: A set of specialized healthcare services that provide support to terminally ill patients and their families.
Hospitalists: Physicians who spend a substantial amount of their time in a hospital setting where they accept admissions to their inpatient services from local primary care providers.
HSA: Health Savings Account. An account established by an employer or an individual to save money toward medical expenses on a tax-free basis. Any balance remaining at the end of the year "rolls over" to the next year.
Immunization: A vaccine that guards against childhood illnesses, such as chicken pox, mumps, and measles, and adult illnesses, such as pneumonia and influenza.
Incorporation By Reference: The method of making a document a part of a contract by referring to it in the body of the contract.
Indemnity Insurance: Traditional, fee-for-service health insurance that does not limit where a covered individual can get care.
Indemnity Wraparound Policy: An out-of-plan product that an HMO offers through an agreement with an insurance company.
Independent Agents: Agents that represent several health plans or insurers and are not employed by any of the companies they represent.
Individual Market: A market segment composed of customers not eligible for Medicare or Medicaid who are covered under an individual contract for health coverage.
In-Network: Providers or health care facilities which are part of a health plan's network of providers with which it has negoiated a discount. Insured individuals usually pay less when using an in-network provider,
because those networks provide services at lower cost to the insurance companies with which they have contracts.
Insolvency: A situation that occurs when an organization's assets or resources are not adequate to cover its debts and obligations.
IPA: Independent Practice Association. similar to HMOs, except that individuals receive care in a physician's own office, rather than in an HMO facility.
Individual Health Insurance: Health insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than
for a group policy, but you may not qualify for a group plan.
Joint Venture: A type of partial structural integration in which one or more separate organizations combine resources to achieve a stated objective.
Justice: An ethical principle, which, when applied to managed care, states that managed care organizations and their providers allocate resources in a way that fairly distributes benefits and burdens among the members.
Length Of Stay: The number of days, counted from the day of admission to the day of discharge, that a plan member is confined to a hospital or other facility for each admission.
Liabilities: All debts and obligations of a health insurance or other company.
Limitations: a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
Long-Term Care Insurance: Coverage that pays for all or part of the cost of home health care services or care in a nursing home or assisted living facility.
Loss Rate: The number and timing of losses that will occur in a given group of insureds while the coverage is in force.
Long-Term Disability Insurance: Pays an insured a percentage of their monthly earnings if they become disabled.
LOS: Length of Stay.
Mail-Order Pharmacy Programs: Programs that offer drugs ordered by phone or the internet and delivered through the mail to plan members at a reduced cost.
Managed Care: An organized way of getting health care services and paying for care. Managed care plans feature a network of physicians, hospitals, and other providers who participate in the plan. In some plans, covered individuals must see an in-network provider; in other plans, covered individuals may go outside of the network, but they will pay a larger share of the cost.
Managed Dental Care: Any dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.
Management Services Organization (MSO): An organization owned by a hospital or a group of investors, that provides management and administrative support to individual physicians or small practices to relieve them of non-medical business matters so they can concentrate on the clinical aspects of their practice.
Market Segmentation: Dividing a large market for a product or service into smaller, more manageable subsets or groups of customers.
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 Lifetime Benefit: The maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
MBHO: Managed Behavioral Health Organization.
McCarran-Ferguson Act: A federal act that placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.
MCO: Managed Care Organization.
Medicaid: A Federal program administered by the States to provide health care for certain poor and low-income individuals and families. Eligibility and other features vary from state to state.
Medical Foundation: A non-profit entity, usually created by a hospital or health system, that purchases and manages physician practices.
Medical Underwriting: The evaluation of health questionnaires submitted by all proposed plan members to determine the insurability of the group.
Medically Appropriate Services: Diagnostic or treatment measures for which the expected health benefits exceed the expected risks by a margin wide enough to justify the measures.
Medically Necessary Services: Services or supplies provided by a physician or other healthcare provider in accordance with the standards of good medical practice. The services cannot be solely
for the convenience of the member, the member's family, the physician, or other healthcare provider. Additionally, the service or treatment must be furnished in the least intensive type of medical care setting
required by the patient's condition.
Medically Needy Individuals: Individuals who meet the financial resource requirements of categorically needy individuals, but whose monthly income exceeds the specified maximums for Medicaid or other
government medical assistance programs.
Medicare: A federal government program established in the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.
Medicare Part A: The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization, and hospice care.
Medicare Part B: The Medicare component that provides benefits to cover the costs of physicians' professional services, whether the services are provided in a hospital, a physician's office, an extended-care facility, a nursing home, or an insured's home.
Medicare Supplement: A private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.
Medigap Policies: Individual medical expense insurance policies sold by state-licensed private insurance companies. These policies are designed to pay for some of the costs that Medicare does not cover.
Mental Health Parity Act: MHPA. A law which prohibits group health plans from applying more restrictive annual and lifetime limits on coverage for mental illness than for physical illness.
Military Health System: MHS. A worldwide healthcare system operated by the U.S. Department of Defense that focuses its efforts on population health improvement by integrating the delivery of healthcare services for active-duty personnel,
retirees, and the families of active-duty personnel and retirees.
MSO: Management Services Organization.
Multiple Employer Trust (MET): A trust consisting of groups of small employers in the same industry, formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than would be available to each of the employers individually.
Mutual Company: A company owned by its members and/or its policy owners.
National Practitioner Data Bank (NPDB): A database maintained by the federal government that contains information on physicians and other medical practitioners against whom medical malpractice claims have been settled or other disciplinary actions have been taken.
Network: The group of physicians, hospitals, and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members. Providers in the network have agreed to follow the
terms of the plan to which they are contracted, including the fee schedule associated with that plan. Insured individuals typically pay less for using a network provider than they would if they used a provider outside of the network.
Network Model HMO: An HMO that contracts with more than one group practice of physicians or specialty groups.
NMHPA: Newborns' and Mothers' Health Protection Act.
No Balance Billing Provision: A provider contract clause which states that the provider agrees to accept the amount the plan pays for medical services as payment in full and not to bill plan members for additional amounts other than unpaid co-payments, coinsurance, and deductibles.
Open-Ended HMOs: HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional's services under a traditional indemnity plan.
Open Enrollment: A set time of year when you can enroll in health insurance or change from one plan to another without benefit of a qualifying event (e.g., marriage, divorce, birth of a child/adoption, or death of a spouse).
Open-panel HMOAn HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a provider.
Open PHO: A type of physician-hospital organization that is available to all of a hospital's eligible medical staff.
Out-Of-Pocket Maximums: Dollar amounts set by managed care organizations that limit the amount a member has to pay out of his/her own pocket for particular healthcare services during a particular time period.
Outpatient Care: Treatment provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility. Many facilities have "short stay" units designed specifically
for this purpose. The term "outpatient" is also used synonymously with ambulatory to describe health care facilities where procedures are performed.
Out-of-Network: Physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan - usually an HMO or PPO.
Out-of-Plan: See Out-of-Network.
PCP: See Primary Care Provider.
PHO: See Physician-Hospital Organization.
Physician-Hospital Organization: PHO. A joint venture between a hospital and many or all of its admitting physicians whose primary purpose is contract negotiations with MCOs and marketing.
Point-Of-Service Plan: A form of managed care plan in which primary care physicians coordinate patient care but there is more flexibility in choosing doctors and hospitals than in an HMO.
Pooling: The practice of underwriting a number of small groups as if they constituted one large group.
PPO: Preferred Provider Organization. A form of managed care in which you have more flexibility in choosing physicians and other providers than in an HMO. You can see both participating and nonparticipating providers, but your out-of-pocket expenses will be lower if you see only plan providers.
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 Condition: In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.
Preferred Provider Organization: See PPO.
Premium: The amount you pay to belong to a health plan. If you have employer-sponsored health insurance, your share of premiums usually are deducted from your pay.
Premium Taxes: State income taxes levied on an insurer's premium income.
Prepaid Care: Healthcare services provided to an HMO member in exchange for a fixed, monthly premium paid in advance of the delivery of medical care.
Primary Care: General medical care that is provided directly to a patient without referral from another physician. It is focused on preventive care and the treatment of routine injuries and illnesses.
Primary Care Provider: Usually a family practice doctor, internist, obstetrician-gynecologist, or pediatrician. He or she is your first point of contact with the health care system, particularly if you are in a managed care plan.
Prior Authorization: A program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review.
Prospective Review: The review and possible authorization of proposed treatment plans for a patient before the treatment is implemented.
Provider: A health professional who provides health care services.
Provider Profiling: The collection and analysis of information about the practice patterns of individual providers.
Quality: In a health care context, a managed care organization's success in providing health care and other services in such a way that plan members' needs and expectations are met.
Rate Spread: The difference between the highest and lowest rates that a health plan charges small groups. The National Association of Insurance Commissioners' Small Group Model Act limits a plan's allowable rate spread to 2 to 1.
Reactive Change: Change that is controlled, but rarely planned and that can lead to positive or negative results.
Reasonable And Customary Charge: The average fee charged by a particular type of health care practitioner within a geographic area. This term is often used by medical plans as the amount of money they will approve for a specific test or procedure.
Receivership: A situation in which the state insurance commissioner, acting for a state court, takes control of and administers an HMO's assets and liabilities.
Recredentialing: A health care organizations periodic review of the qualifications of a current network provider to verify that the provider continues to meet the standards for participation in the network. See Credentialing.
Retrospective Review: A review that occurs after treatment is completed in order to authorize payment and medical necessity and appropriateness of care.
Rider: A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).
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. An example is cigarette smoking, which increases the risk of cancer.
Risk Adjustment: The statistical adjustment of outcomes measures to account for risk factors that are independent of the quality of care provided and beyond the control of the plan or provider, such as the patient's gender and
age, the seriousness of the patient's condition, and any other illnesses the patient might have.
SCHIP: See State Children's Health Insurance Program.
Screening: Preventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem.
Second Opinion: A medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual.
Section 1115 Waivers: Waivers that gave states the authority to offer more comprehensive services to specified categories of Medicaid recipients through demonstration projects.
Segments: Subsets or manageable groups of customers in a total market.
Self-Funded Plan: A health plan under which an employer or other group sponsor, rather than an insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as a self-insured plan.
Self-Insured Plan: See Self-Funded Plan.
Senior Market: A market segment that is comprised largely of persons over age 65 who are eligible for Medicare benefits.
Service Quality: A managed care organization's success in meeting the non-clinical customer service needs and expectations of plan members.
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 Medical: Temporary coverage for a short period of time, usually from 30 days to six months.
Specialist: A healthcare professional whose practice is limited to a certain branch of medicine, specific procedures, certain age categories of patients, specific body systems, or certain types of diseases.
Staffing Ratios: Ratios that relate the number of providers in the network to the number of enrollees in the health plan.
Standard Of Care: A diagnostic and treatment process and guidelines that a clinician should follow for a certain type of patient, illness, or clinical circumstance.
State Children's Health Insurance Program: A program established by the Federal Balanced Budget Act designed to provide health assistance to uninsured, low or lower-middle income children either
through separate programs or through expanded eligibility under state Medicaid programs.
State-Mandated Benefits: Specific benefits included in health insurance plans because a state has passed a law requiring them to do so.
Step-Down Unit: A ward or section of a ward in a hospital that is devoted to delivering sub-acute care to patients following a period of acute care.
Stop-loss Insurance: The dollar amount of claims filed for eligible expenses at which which point you've paid 100% of your out-of-pocket and the insurance begins to pay at 100%.
Termination Provision: A provider contract clause that describes how and under what circumstances the parties may end the contract.
Termination With Cause: A contract provision, included in all standard provider contracts, that allows either the health care organization or the provider to terminate the contract when the other party does not live up to its contractual obligations.
Three-Tier Copayment Structure: A pharmacy benefit copayment system under which a member is required to pay one co-payment amount for a generic drug, a higher co-payment amount for a brand-name drug included on the health plan's formulary, and an even higher co-payment amount for a non-formulary drug.
TRICARE: A Department of Defense, regionally managed health-care program for active duty and retired members of the uniformed services and their families that combines military healthcare resources and networks of civilian healthcare professionals. Formerly known as CHAMPUS.
TRICARE Extra: A reduced fee-for-service (FFS) plan similar to the network portion of a PPO.
TRICARE Prime: An enrollment-based managed care option designed to provide coordinated care managed by a primary care manager (similar to a PCP).
TRICARE Standard: A fee-for-service plan that allows participants to use TRICARE authorized providers or non-network providers.
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.
Two-Tier Copayment Structure: A pharmacy benefit co-payment system under which a member is required to pay one co-payment amount for a generic drug and a higher co-payment amount for a brand-name drug.
UCR: See Usual, Customary and Reasonable Fee.
Underwriter: The company that assumes responsibility for the risk, issues insurance policies and receives premiums.
Underwriting: The process of identifying and classifying the risk represented by an individual or group.
Underwriting Impairments: Factors that tend to increase an individual's risk above that which is normal for his or her age.
Underwriting Manual: A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.
Usual, Customary, And Reasonable Fee: UCR or Covered Expenses. The amount commonly charged for a particular medical service by physicians within a particular geographic region and used by traditional health insurance companies as the basis for physician reimbursement.
Waiting Period: A period of time when you are not covered by insurance for a particular problem.
WHCRA: See Women's Health and Cancer Rights Act.
Withhold: A percentage of a provider's payment that is "held back" during the plan year to offset or pay for any cost overruns for referral or hospital services. Any part of the withhold not used for these purposes is distributed to providers.
Womens Health and Cancer Rights Act: WHCRA. A law which requires health plans that offer medical and surgical benefits for mastectomy to provide coverage for reconstructive surgery following mastectomy.
Workers' Compensation: A state-mandated insurance program that provides benefits for healthcare costs and lost wages to qualified employees and their dependents if an employee suffers a work-related injury or disease. Called L & I - Labor and Industries
insurance, in the State of Washington.
Workers' Compensation Indemnity Benefits: Benefits that replace an employee's wages while the employee is unable to work because of a work-related injury or illness.
