Health insurance
protection against the financial consequences of poor health
Medical expense insurance
protection against financial losses that result from medical bills because of an accident or illness
Major medical insurance
a medical insurance plan designed to provide substantial protection against catastrophic medical expenses. There are few exclusions and limitations, but deductibles and coinsurance are common.
Preexisting-conditions provision
a provision that excludes coverage for a limited period of time for a physical or mental condition for which a covered person in a benefit plan received treatment or medical advice within a specified period before becoming eligible for coverage
Deductible
the initial amount or portion of covered losses that is borne by the insured, rather than by the insurance company
Common accident provision
a provision in a major medical expense contract whereby if two or more members of the same family are injured in the same accident, the covered medical expenses for all family members will, at most, be subject to a single deductible, usually equal to the
Coinsurance (medical expense insurance)
the percentage of covered expenses under a medical insurance plan that is paid by the insurance company once a deductible is satisfied. Eighty percent is common.
Stop-loss limit
the maximum amount of out-of-pocket medical expenses that a covered person must pay in a given period (usually 1 year). after this limit is reached, future copayments and deductibles are waived for the remainder of the period.
Preadmission certification
a requirement under many medical expense plans that a covered person or hid or her physician obtain prior authorization for an nonemergency hospitalization
Second surgical opinions
a cost-containment strategy under which covered persons are encouraged or required to obtain the opinion or another physician after certain categories of surgery have been recommended. If a second opinion is mandatory, benefits are reduced if the second o
Extended care facilities
a health care facility for a person who no longer requires the full level of medical care provided by a hospital but des need a period of convalescence under supervised medical care. Also known as a skilled nursing facility.
Home health care
medical care that is received at home. Care is usually part-time and performed under a plan prescribed by a physician.
Hospice care
a health care facility or service that provides benefits to terminally ill persons. The emphasis is on easing the physical and psychological pain associated with dying rather than on curing the medical condition.
Birthing centers
a facility, separate from a hospital, designed to provide a homelike atmosphere for the delivery of babies. Deliveries are performed by nurse-midwives, and mothers and babies are released shortly after birth
Managed care
a process to deliver cost-effective health care without sacrificing quality or access. Common characteristics include controlled access to providers, comprehensive case management, preventive care, risk sharing, and high-quality care
Health maintenance organizations (HMO)
a managed system of health care that provides a comprehensive array of medical services on a prepaid basis to voluntarily enrolled persons living within a specific geographic region. HMOs both finance health care and deliver health services. There is an e
Preferred provider organization (PPO)
benefit plan that contracts with preferred providers to obtain lower-cost care for plan members. Also refers to health care providers that contract with employers or others to provide medical care services at a reduced fee.
Exclusive-provider organization (EPO)
a variation of a preferred-provider organization in which coverage is not provided outside the preferred-provider network except in those infrequent cases where the network does not have an appropriate specialist
Point of service (POS) plan
a hybrid arrangement that combines aspects of a traditional medical expense plan with an HMO or PPO. At the time of medical treatment, a participant can elect whether to receive treatment within the plan's network or outside the network.
Consumer-directed medical expense plan
an approach to medical expense insurance that gives employees increased choices and responsibilities involving their health care
Defined-contribution medical expense plan
a plan under which the employer makes a fixed dollar contribution that an employee can use toward paying the cost of medical expense coverage, regardless of the premium
High-deductible health plan
medical expense plan with a deductible as high as $5,000 or more. When used in an employment setting, the employer may contribute a lower or equal amount to a savings account from which employees can pay medical expenses not covered because of the deducti
Health reimbursement arrangement (HRA)
an account funded with employer dollars from which an employee can withdraw amounts to pay medical expenses that are not covered under a high deductible medical expense plan
Carve-out (medical expense insurance)
coverage under a medical expense plan that has been singled out for individual enjoyment by a party other than the employer or the employee's primary health care provider
Coordination-of-benefits (COB) provision
a provision in most group medical expense plans under which priorities are established for the payment of benefits if an individual is covered under more than one plan. Coverage as an employee is generally primary to coverage as a dependent. When parents
Medicare carve-out
an employer provided medical expense plan for persons over age 65 under which benefits are reduced to the extent that they are payable under Medicare for the same expense
Medicare supplement
an individual or employer-provided medical expense plan for persons aged 65 or older under which benefits can be provided for certain specific expenses not covered under Medicare. These can include a portion of expenses not paid by Medicare because of ded
Limited-benefit plan
a medical expense plan that generally provides first-dollar coverage for certain medical expenses but has significantly lower benefits for catastrophic expenses than do other types of medical expense plans