Health-care plans
Cover the costs of services that promote sound physical and mental health, including physical examinations, diagnostic testing, surgery, hospitalization, psychotherapy, dental treatments, and corrective prescription lenses for vision deficiencies.
Fully Insured Plans
Are based on a contractual relationship with one or more insurance companies to provide health-related services for employees and their qualified dependents.
Individual Coverage
A person chooses to purchase health-care coverage outside the employment setting or herself and qualifed dependents.
Group Coverage
Basis for employer sponsored health care plans
Insurance Policy
Contractual relationship specifying the amount the insurer pays, for medical claims.
Premium
An amount paid by the employer to the insurer to establish and maintain health-care plans.
Underwriting
The term and premium decision making process using morbidity, and mortality tables as a reference.
Mortality Table
Indicate yearly probabilities of death based on such factors as age and sex.
Morbidity Table
Express annual probabilities of the occurrence of health problems.
Experience Rating
Indicate the incidence, type, and financial cost of claims for groups (i.e. everyone as a whole covered under a group plan). Experience ratings hold employers accountable for past claims, thus establishing the basis for charging different premiums.
Self-funded Plan
Employer defined health-plan. Employer determines what benefits to offer, pays medical claims for employees and their families, and assumes all of the risk. Employers pay claims directly from their own assets, either current cash flow, or funds set aside in advance for potential future claims.
Single coverage
Only the covered employee receives health care benefits.
Family Coverage
Covered employee and qualified dependents receive health care benefits.
Multiple-payer system
More than one party is responsible for covering the cost of health care. (i.e. government, employers, employees, or individuals not currently employed).
Single-payer system
Government run healthcare system. Government regulates the health-care system and uses tax-payer dollars to fund health care, as in Canada and some other countries.
Universal health care systems
Single payer systems as required that all citizens have access to quality health care regardless of their ability to pay.
HMO Act of 1973
By providing financial incentives to companies, subject to becoming federally qualified, the HMO act of 1973 promoted the the use of health maintenance organizations.
Hospitalization benefits
Defray expenses associated with treatment in hospitals. Plans distinguish between inpatient and outpatient benefits.
Inpatient benefits
Cover expenses associated with overnight hospital stays.
Outpatient benefits
Cover expenses not associated with overnight stays in hospitals.
UCR (usual, customary, reasonable)
Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances.
ERISA
Governs pension and welfare plans. Health benefits are considered welfare plans.
Women's Health and Cancer Rights Act
An amendment to ERISA. Requires group health plans to provide medical and surgical benefits for mastectomies. Medical and surgical benefits must cover reconstruction of either breast for a symmetrical appearance.
ADA
Prohibits discrimination against people with disabilities.
Individual Mandate
Requirement that individuals get health insurance or pay a tax penalty to the federal government.
Patient Protection and Affordable Care Act (PPACA)
A law tat mandates health insurance coverage and sets minimum standards for insurance.
Employer Mandate
Requirement that employers with at least 50 employees are required to offer affordable health insurance to it's full time employees.
Grandfathered plans
Health plans that existed prior to the PPACA enactment date.
Non-Grandfathered plans
New health plans or preexisting plans that have been substantially modified after March 23, 2010
Coinsurance
Percentage of covered expenses paid by the insured.
Co-payment
Fixed fee paid by the patient at the time of an office visit.
Deductable
Amount an individual pays for health-care services before benefits become active.
Out-of-Pocket maximum
The maximum amount the insured will have to pay each year for health care expenses.
Essential benefits
Services provided in ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavior health treatment, prescription drugs, rehabilitation services and devices, laboratory services, preventative and wellness services and chronic disease mgmt, and pediatric services including oral and vision care.
Cadillac tax
Is applied to high-cost employer-sponsored health plans. Plans costing more than 10,500 (single) & 27,500 for family.
National Association of Insurance Commissioners (NAIC)
Non-profit organization, addresses issues concerning the supervision of insurance within each state (www.naic.org)
Pre-paid plan
Pays health care providers a fixed amount according to the number of individuals covered by the plan.
Indemnity Plan
Reimburses either health-care provider or patient.
Fee-for-service (FFS) plan
Provide protection against health care expenses in the form of cash benefit paid to the employee or directly to the health care provider after receiving health-care services.
Managed care plans
Emphasize cost control by limiting an employee's choice of doctors and hospitals. These plans also provide protection against health care expenses in the form of prepayment to health care providers.
Open-access HMO
Pre-paid plans and require the use of network health care providers with one exception; emergency care outside of the network.
Primary Care Physician (PCP)
The physician responsible for directing all of a patient's medical care and determining whether the patient should be referred for specialty care.
prepaid group practice
Provide medical care for a set amount.
Staff Model HMO
Own a health maintenance organization that hires its own health care providers and support staff.
Group Model HMO
Primarily use contracts with established practices of physicians that cover multiple specialties. They do not directly employ physicians.
Network Model HMO
Contract with two or more independent practices of physicians. HMO's usually compensate physicians according to a capped fee schedule.
Individual Practice Association (IPA)
Partnership of independent physicians, health professionals, and group practices. IPA's charge lower fees to designated populations of employees than fees charged to others.
Exlusive Provider Organization (EPO)
Operate similarly to PPO's, but systems differ. EPO's are more restrictive the PPO plans. EPO's offer reimbursement for services provided within the established network.
Preferred Provider Organization (PPO)
A select group of health-care providers agrees to furnish health-care services to a given population at a lower level of reimbursement than is the case for fee-for-service plans.
Point of Service Plan (POS)
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Second Surgical Opinion
A cost-management strategy that encourages or requires patients to obtain the opinion of another doctor after a physician has recommended that a non-emergency or elective surgery be performed.
Yearly limits
Maximum amount a plan will cover each year.
Lifetime limits
Maximum amount of coverage a person will receive as long as they are covered by the plan.