Glossary of Terms
| Title | Definition |
|---|---|
| Accumulation Period |
Timeframe within a policy period in which deductible and out-of-pocket amounts are calculated. For most health insurance policies, the accumulation period is a calendar year. |
| Affordable Care Act (ACA) |
The Patient Protection and Affordable Act (PPACA) is the landmark health reform legislation passed by the 111th Congress and signed into law by President Obama in March 2010. The legislation includes a long list of health related provisions that began taking effect in... |
| Agent |
Licensed salespersons who represent one or more health insurance companies and presents their products to consumers. |
| Agent of Record |
The insurance agent recognized by a client to represent the client’s interests in doing business with an insurance company. |
| Any Willing Provider Laws |
Legislation that requires health care plans to accept into their PPO and HMO networks any provider willing to agree to the network’s terms and conditions. |
| Appeal |
Request made to a payer to reconsider a decision, such as a claim denial or denied prior authorization request. Most appeals must be submitted in writing within a specified period. |
| Arkansas Continuation Act |
AR Code 23-86-114 & 115 applies to a company that has less than 20 employees and is not COBRA eligible. It allows an employee that has been covered under the employers group plan for at least 3 months prior to be eligible to continue benefits for up to 120 days... |
| Title | Definition |
|---|---|
| Beneficiary |
A person eligible for benefit under a health insurance policy. |
| Benefit |
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss. |
| Benefit Cap |
Total dollar amount that a payer will reimburse for covered health care services during a specified period, such as one year. |
| Board Certified |
A physician who has passed examinations given by a medical specialty group and who has, as a result, been certified as a specialist in this area of practice. |
| Brand-name Drug |
Prescription drugs marketed with a specific brand name by the company that manufactures it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins... |
| Broker |
A licensed legal representative of the policyholder, who negotiates with an insurance company on behalf of a customer, but is paid a commission by the insurance company. |
| Title | Definition |
|---|---|
| Case Management |
A process whereby an insured person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner. |
| Case Manager |
A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients. |
| Centers of Excellence |
Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants. |
| Certificate of Coverage |
A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company. |
| Claim |
Form submitted to a payer (by a health care provider or patient) to request payment for items or services. |
| Co-insurance |
Cost-sharing arrangement between an insured person and the health insurance company in which the insured person is required to pay a percentage of the cost for the health care services received. Coinsurance typically applies after satisfaction of a deductible. For example, 80% coinsurance may... |
| Co-payment (Co-pay) |
Co-payment is a predetermined fee, in addition to what health insurance covers, that an individual pays for health care services. For example, a PPO may require a $20 “co-payment” for normal services delivered during a physician office visit. |
| Consolidated Omnibus Budget Reconciliation Act (COBRA) |
The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for employees and their dependents for 18 months after the employee leaves the job. Longer... |
| Contract Year |
The period of time from the effective date of the contract to the expiration date of the contract. A contract year is typically 12 months long, but not necessarily from January 1 through December 31. |
| Coordination of Benefits (COB) |
A provision in the contract that applies when a person is covered under more than one health insurance plan. It requires that payment of benefits be coordinated by all plans to eliminate over-insurance or duplication of benefits. |
| Covered Benefit |
A health service or item that is included in a health plan, and that is partially or fully paid by the health plan. |
| Credentialing |
The process used by health insurance companies to examine and verify the medical qualifications of health care providers who want to participate in the PPO or HMO network. |
| Creditable Coverage |
Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. See “HIPPA”. |
| Title | Definition |
|---|---|
| Deductible |
Cost-sharing arrangement between an insured person and health insurance company in which the insured person will be required to pay a fixed dollar amount of covered expenses each year before the health insurance company will reimburse for covered health care expenses. Generally, an insured... |
| Deductible Carry Over Credit |
Charges applied to the deductible for services during the last 3 months of a calendar year which may be used to satisfy the following year’s deductible. |
| Denial Of Claim |
Refusal by a health insurance company to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional. |
| Dependent |
A covered person who relies on another person for support or obtains health coverage through a spouse or parent who is the covered person under a health plan. |
| DRG (Diagnostic Related Group) |
A Medicare-developed healthcare cost schedule in which medical service providers are assigned a uniform payment for specific services. |
| Title | Definition |
|---|---|
| Effective Date |
The date health insurance coverage begins. |
| Eligible Expenses |
The lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan. |
| Employer Mandate |
Effective 1/1/2014 the new health reform legislation requires employers with 50 or more employees to provide health coverage to those employees and sets a minimum baseline of coverage and employer contributions. Employers who do not comply will face annual penalties based on the number of... |
| Employer tax credits |
Employer tax credits- or Small Business Health Care Tax Credits – provide a tax credit of up to 35 percent of small business premium costs in 2010 – with that rate increasing to 50 percent in 2014. Who’s eligible? Employers with fewer than 25 full-time workers and average annual wages less than... |
| Enrollee |
The person who is the primary insured. Under an individual or family policy, this person is the applicant. Under an employer-sponsored group health policy, this person is the employee. |
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