24 Hour Approval: "24 Hour Approval" is a special feature offered on some health insurance plans. When you apply for coverage under plans offering "24 Hour Approval", you can be advised via email of the insurance company's coverage decision within 24 hours.
Access: The availability of medical care. The quality of one's access to medical care is determined by location, transportation options, and the type of medical care facilities available in the area, etc..
Accident: For health insurance purposes, an accident is an unforeseen, unexpected and unintended event resulting in bodily injury.
Accumulation Period: The period of time during which an insured person incurs eligible medical expenses toward the satisfaction of a deductible.
Actively-at-work: Most group health insurance policies state that if an employee is not "actively-at-work" on the day the policy goes into effect, the coverage will not begin until the employee returns to work.
Actual Charge: The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.
Actuary:A person professionally trained in the mathematical and statistical aspects of the insurance industry.
Actuaries frequently calculate premium rates, reserves and dividends and assist in estimating the costs and savings of benefit changes.
Acupuncture: Typicablly, acupuncture services include services performed by a licensed acupuncturist.
Acute Care: Medical care administered, frequently in a hospital or by nursing professionals, for the treatment of a serious injury or illness or during recovery from surgery. Medical conditions requiring acute care are typically periodic or temporary in nature, rather than chronic.
Additional Drug Benefit List: see Drug Maintenance List.
Administrative Services Only (ASO) Agreement: A business contract under which an insurance company agrees to perform specific administrative duties for the maintenance of a self-funded health insurance plan.
Admissions/1,000: A statistic used by health insurance companies describing the number of hospital admissions for each 1000 persons covered under a health insurance plan within a given time period.
Admits: Hospital admissions. A term used to describe the number of persons admitted to a hospital within a given period.
Adverse Selection: The tendency of those who experience greater health risks to apply for and continue their coverage under any given health insurance plan. When adverse selection increases, health insurance companies experience greater expenses and may raise rates.
Age Change: For insurance purposes, this is the date on which a person's age changes. Note that this may not correspond with the individual's actual birthday, but may fall midway between birthdays. An age change may result in an increase in rates.
Age Limits: Ages below and above which an insurance company will not accept applications or renew policies.
Age/Sex Factor: A factor employed by insurance companies in the underwriting process, used to determine a group's risk of incurring medical costs, based on the ages and genders of the persons in that group.
Agent: A state-licensed individual or entity representing one or more insurance companies. An agent solicits and facilitates the sale of insurance contracts or policies and provides services to the policyholder on behalf of the insurer. See also, Broker.
Allied Health Personnel: Also referred to as paramedical personnel, these are health workers (often licensed) who perform duties that would otherwise be performed by physicians, optometrists, dentists, podiatrists, nurses and chiropractors.
Allowable Charge: -also referred to as the Allowed Amount, Approved Charge or Maximum Allowable. See also, Usual, Customary and Reasonable Charge. This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. The Allowable Charge is typically a discounted rate rather than the actual charge.
It may be helpful to consider an example: You have just visited your doctor for an earache. The total charge for the visit comes to $100. If the doctor is a member of your health insurance company's network of providers, he or she may be required to accept $80 as payment in full for the visit - this is the Allowable Charge. Your health insurance company will pay all or a portion of the remaining $80, minus any co-payment or deductible that you may owe. The remaining $20 is considered provider write-off. You cannot be billed for this provider write-off. If, however, the doctor you visit is not a network provider then you may be held responsible for everything that your health insurance company will not pay, up to the full charge of $100.
This term may also be used within a Medicare context to refer to the amount that Medicare considers payment in full for a particular, approved medical service or supply.
Allowable Costs: Charges for healthcare services and supplies for which benefits are available under your health insurance plan.
Allowed Amount: -see Allowable Charge.
Alternate Delivery System: Healthcare services or facilities which "deliver" care that is more cost-effective than that provided in a hospital. Alternate Delivery Systems may include skilled nursing facilities, hospice programs and home health care services.
Alternative Medicine: Any medical practice of form of treatment not generally recognized as effective by the medical community at large. Alternative medicine may encompass a broad range of services and practices including acupuncture, homeopathy, aromatherapy, naturopathy, etc.. Many insurance companies do not provide coverage for these services.
Ambulatory Care: Medical care rendered on an outpatient basis and which may include diagnosis, certain forms of treatment, surgery and rehabilitation. See also, Ambulatory Setting.
Ambulant service: Means service that is performed in a facility approved under the Health Practice Law (2013 Revision) on a patient who enters and leaves the facility after recovery, within twenty-four hours and includes outpatient radiation, chemotherapy and surgical services and procedures conducted in an ambulant facility.
Ambulatory Setting: Medical facilities such as surgery centers, clinics and offices in which healthcare is provided on an outpatient basis.
Ancillary Fee: An extra fee sometimes associated with obtaining prescription drugs which are not listed on a health insurance plan's formulary of covered medications.
Ancillary Products: Additional health insurance products (such as vision or dental insurance) that may be added to a medical insurance plan for an additional fee.
Ancillary Services: Supplemental healthcare services such as laboratory work, x-rays or physical therapy that are provided in conjunction with medical or hospital care.
Annual limit: Many health insurance plans place dollar limits upon the claims the insurer will pay over the course of a plan year. Beginning September 23, 2010, PPACA phases annual dollar limits will be phased out over the next 3 years until 2014 when they will not be permitted for most plans. There is an exception to this phase out for Grandfathered Plans. Except for Grandfathered Plans, beginning September 23, 2012 annual limits can be no lower than $2 million. Except for Grandfathered Plans, beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited.
Application Fee: The health insurance company may require a one-time application fee. Some insurance companies may refund this fee if the application is not approved. See More Insurance Plan Details section for additional information.
Approved Charge: -see Allowable Charge.
Approved Health Care Facility or Program: A medical facility or healthcare program (often organized through a hospital or clinic) that has been approved by a health insurance plan to provide specific services for specific conditions.
Assignment of Benefits: The payment of health insurance benefits to a healthcare provider rather than directly to the member of a health insurance plan.
Attending Physician Statement (APS): A physician's assessment of a patient's state of health as outlined in office notes and test results compiled by the physician. An APS may be requested by an insurance company in lieu of a medical examination in order to determine the state of a health insurance applicant's health for underwriting purposes.
Balance Billing: The amount you could be responsible for (in addition to any co-payments, deductibles or coinsurance) if you use an out-of-network provider and the fee for a particular service exceeds the allowable charge for that service.
Basic Hospital Expense Insurance: -see Hospitalization Insurance.
Bed Days/1,000: A statistic used by health insurance companies describing the number of inpatient hospital days for each 1000 persons covered under a health insurance plan within a given time period.
Benefit: A general term referring to any service (such as an office visit, laboratory test, surgical procedure, etc.) or supply (such as prescription drugs, durable medical equipment, etc.) covered by a health insurance plan in the normal course of a patient's healthcare.
Benefit Level: The maximum amount a health insurance company agrees to pay for a specific covered benefit.
Benefit Package: A description of the healthcare services and supplies that a health insurance company covers for members of a specific health insurance plan.
Benefit Riders: This term may be used to describe ancillary products purchased in conjunction with a medical insurance plan.
Benefit Year: The annual cycle in which a health insurance plan operates. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall.
Binding Receipt: When you submit an application for health insurance and include an initial payment, the health insurance company may provide you with a binding receipt. A binding receipt indicates that, if coverage is approved, the health insurance company is required to initiate coverage from the date on which payment was received.
Birthday Rule: One method used by health insurance companies to determine which parent's health insurance coverage will be primary for a dependent child, when both parents have separate coverage. Typically, the health insurance plan of the parent whose birthday falls earliest in the year will be considered primary. For more information, see also, COB.
Board-certified: A board-certified physician is one that has successfully completed an educational program and evaluation process approved by the American Board of Medical Specialties, including an examination designed to assess the knowledge, skills and experience required to provide quality patient care in a specific specialty.
Broker: Though sometimes used in a sense synonymous with the term agent, a broker typically works to match applicants with a health insurance company or plan best matched to their needs. The broker is paid a commission by the insurance company, but represents the applicant rather than the insurance company itself.
Business License: A license from a governmental agency authorizing an individual or an employer to conduct business.
Business Structure: A state-designated legal structure that governs business taxes, liability, and operational requirements. Examples include: sole proprietorship, partnership, corporation, or LLC.
COB (Coordination of Benefits): This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy. See also, Non-duplication of Benefits.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985): Federal legislation allowing an employee or an employee's dependents to maintain group health insurance coverage through an employer's health insurance plan, at the individual's expense, for up to 18 months in certain circumstances. COBRA coverage may be extended beyond 18 months in certain circumstances. COBRA rules typically apply when an employee loses coverage through loss of employment (except in cases of gross misconduct) or due to a reduction in work hours. COBRA benefits also extend to spouses or other dependents in case of divorce or the death of the employee. Children who are born to, adopted, or placed for adoption with the covered employee while he or she is on COBRA coverage are also entitled to coverage. All companies that have averaged at least 20 full-time employees over the past calendar year must comply with COBRA regulations.
Capitation: A method of compensation sometimes employed by health insurance companies, in which payment is made to a healthcare provider on a per-patient rather than a per-service basis.
For example, under capitation an HMO doctor may be paid a fixed amount each month to serve as the primary care physician for a specific number of HMO members assigned to his or her care, regardivess of how little or how much care each member needs.
Carrier: Any insurer, managed care organization, or group hospital plan, as defined by applicable state law.
Carry-over Provision: A provision of some health insurance plans allowing medical expenses paid for by the member in the last three months of the year to be carried over and applied toward the next year's deductible.
Case Management: When a member requires a great deal of medical care, the health insurance company may assign the member to case management. A case manager will work with the patient's healthcare providers to assist in the management of the patient's long-term needs, with appropriate recommendations for care, monitoring and follow-up. A case manager will also help ensure that the member's health insurance benefits are being properly and fully utilized and that non-covered services are avoided when possible.
Centers for Medicare and Medicaid Services: Formerly known as the Health Care Financing Administration, the Centers for Medicare and Medicaid Services (CMS) is part of the federal government's Department of Health and Human Services, and is responsible for the administration of the Medicare and Medicaid programs. The CMS establishes standards for healthcare providers that must be complied with in order for providers to meet certain certification requirements.
Certificate of Coverage: A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company.
Chemical Dependency Inpatient: Typically, chemical dependency inpatient services include services relating to the treatment of a chemical dependency that requires a stay at a hospital or other medical facility.
Chiropractic: Typically, chiropractic services include services provided by a licensed chiropractor.
Chronic: In healthcare and insurance terminology, a chronic condition is one that is permanent, recurring or long lasting, as opposed to an acute condition.
Claim: A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider.
Coinsurance: The amount that you are obliged to pay for covered medical services after you've satisfied any co-payment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a healthcare provider.
For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance.
Company: The insurance company that is offering this health insurance plan.
Commission: Means the Health Insurance Commission established under section 3 of the Health Insurance Commission Law (2010 Revision);
Cost-sharing: Health care provider charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance, and co-payments. Balance-billed charges from out-of-pocket physicians are not considered cost-sharing. Beginning in 2014, PPACA limits total cost-sharing to $5,950 for an individual and $11,900 for a family. These amounts will be adjusted annually to reflect the growth of premiums.
Co-payment: A specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a "co-pay." For example, your health insurance plan may require a $15 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.
Current Procedural Terminology: (CPT) Means a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians, which terms and codes are published by the American Medical Association.
Date of Service: The date on which a healthcare service was provided.
Deductible: A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most Indemnity and PPO plans do.
Deductible Carry-over Credit: -see, Carry-over Provision
Department of Health and Human Services: A department of the federal government responsible for certain social service functions, such as the administration and supervision of the Medicare program.
Dependent Coverage: Health insurance coverage extended to the spouse and unmarried children of the primary insured member. Certain age restrictions on the coverage of children may apply.
Designated Mental Health Provider: An organization hired by a health insurance plan to provide mental health and/or substance abuse treatment services.
Drug Formulary: A list of prescription medications selected for coverage under a health insurance plan. Drugs may be included on a drug formulary based upon their efficacy, safety and cost-effectiveness. Some health insurance plans may require that patients obtain preauthorization before non-formulary drugs are covered. Other health insurance plans may require that a patient pay a greater share or all of the cost involved in obtaining a non-formulary prescription.
Drug Maintenance List: A list of commonly prescribed drugs intended for patients' ongoing or long-term use.
Drug Utilization Review (DUR): The process by which health insurance companies evaluate or review the use of prescription drugs for appropriateness in the treatment of a patient.
Durable Medical Equipment (DME): Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc.. Coverage levels for DME often differ from coverage levels for office visits and other medical services.
ERISA (Employment Retiree Income Security Act of 1974): Federal legislation designed to protect the rights of retirees and beneficiaries of benefit plans offered by employers.
Effective Date: The date on which health insurance coverage comes into effect.
Eligibility Date: The date on which a person becomes eligible for insurance benefits.
Eligibility Requirements: Conditions that must be met in order for an individual or group to be considered eligible for insurance coverage.
Eligible Dependent: A dependent (usually spouse or child) of an insured person who is eligible for insurance coverage.
Eligible Employee: An employee who is eligible for insurance coverage based upon the stipulations of the group health insurance plan.
Eligible Expenses: Expenses defined by the health insurance plan as eligible for coverage.
Eligible Person: This term is used to designate a person who is eligible for insurance coverage even though he or she may not be an employee, but rather a member of an organization or union.
Emergency Room: Typically, emergency room services include all services provided when a patient visits an emergency room for an emergency condition. An emergency condition is any medical condition of recent onset and severity, including but not limited to severe pain, that would lead to a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organ or part.
Employee Certificate of Insurance: -see Certificate of Coverage.
Employee Contribution: The portion of the health insurance premium paid for by the employee, usually deducted from wages by the employer.
Employer Contribution: The portion of an employee's health insurance premium paid for by the employer.
Employer Wage and Tax Statement: An employer tax reporting statement submitted to the applicable governmental agency to establish and report the employer's tax responsibilities.
Enrollee: An eligible person or eligible employee who is enrolled in a health insurance plan. Dependents are not referred to as enrollees.
Enrollment: The process through which an approved applicant is signed up with the health insurance company and coverage is made effective. This term may also be used to describe the total number of enrollees in a health insurance plan.
Enrollment Period: The period of time during which an eligible employee or eligible person may sign up for a group health insurance plan.
Episode of illness: Includes any period during which a person receives medical treatment for an illness within sixty days of any previous treatment for the same illness.
EPO(Exclusive Provider Organization): An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. There are no out-of-network benefits.
Essential Benefits: PPACA requires all health insurance plans sold after 2014 to include a basic package of benefits including hospitalization, outpatient services, maternity care, prescription drugs, emergency care, and preventive services among other benefits. It also places restrictions on the amount of cost-sharing that patients must pay for these services.
Estimated Cost: The amount quoted is an estimated cost of the health plan, which is subject to change during the enrollment process of the health plan, the optional benefits you selected, if any, and other relevant factors. It may be the sum of estimated premiums and other recurring charges, if the insurance company has such charges.
Evidence of Coverage: -see Certificate of Coverage.
Evidence of Insurability: When applying for an individual health insurance plan, an applicant may be asked to confirm his or her health condition in writing, through a questionnaire or through a medical examination. When applying for group health insurance, evidence of insurability is only required in specific cases (for instance, when a person fails to enroll in the group plan during the enrollment period).
Examination: In health insurance usage, this generally refers to a medical examination performed as part of an application for a life or health insurance plan. See, Evidence of Insurability.
Exclusions: Specific conditions, services or treatments for which a health insurance plan will not provide coverage.
Experimental or Investigational Procedures: Any healthcare services, supplies, procedures, therapies or devices the effectiveness of which a health insurance company considers unproven. These services are generally excluded from coverage.
Explanation of Benefits (EOB): A statement sent from the health insurance company to a member listing services that were billed by a healthcare provider, how those charges were processed, and the total amount of patient responsibility for the claim.
Extended Coverage: A provision of some health insurance plans allowing for coverage of certain healthcare services after the member is no longer covered on the plan. For example, a member's maternity benefits may be extended beyond the expected end of coverage if the woman was already receiving covered maternity services.
Extension of Benefits: A provision of some health insurance plans allowing for coverage to be extended beyond a scheduled termination date. The extended coverage is made available only when the member is disabled or hospitalized as of the intended termination date, and continues only until the patient leaves the hospital or returns to work.
Fees: Includes any fees or charges prescribed to be paid by patients of health care facilities for treatment, nursing, accommodation, attendance, food, dressings, drugs, medicines or other supplies or services rendered to such patients by the health care facilities.
Fee-For-Service Plan: -see Indemnity Plan.
Fictitious Business Name Statement: A certificate provided by a local or state governmental office that clarifies the true owner of a business or company. When a company or individual conducts business under an assumed name, this is referred to as a "fictitious name." It may also be referred to as a "trade name" or "doing-business-as (DBA)" name. For the purposes of group health insurance, this statement confirms the identity of the business applying for coverage with a health insurance company.
Formulary: -see Drug Formulary.
Gatekeeper: A term used to describe the role of the primary care physician in an HMO plan. In an HMO plan, primary care physicians serves as the patient's main point of contact for healthcare services and refer patients to specialists for specific needs.
Generic Drug: A drug which is exactly the same as a brand name prescription drug, but which can be produced by other manufacturers after the brand name drug's patent has expired. Generic drugs are usually less expensive than brand name drugs.
Grace Period: A time period after the payment due date, during which insurance coverage remains in force and the policyholder may make a payment without penalty.
Grandfathered plan: Health insurance coverage that existed as of March 23, 2010 that is subject only to certain provisions of the PPACA. Any policy sold in the individual health insurance market after March 23, 2010 will not be grandfathered even if the product sold was offered before that date. New employees may be added to group plans that are grandfathered, and new family members may be added to all grandfathered plans. If you're not sure whether you have a Grandfathered plan, please contact the plan directly.
Grievance Procedure: The procedure by which a member or healthcare provider is allowed to file a complaint with a health insurance company and seek a remedy.
Group: A number of individuals covered under a single health insurance contract, usually a group of employees.
Group Health Insurance: A health insurance plan that provides benefits for employees of a business or members of an organization, as opposed to individual and family health insurance.
Guaranteed Issue: A term used to describe insurance coverage that must be issued regardivess of health status. In most states, group health insurance plans are often described as guaranteed issue plans, because a health insurance company generally cannot refuse coverage to a qualifying business or organization based on the health status of their employees or members. In some states, all health insurance plans are guaranteed issue.
Guaranteed Renewable Contract: A contract under which the insured person has the right (usually up to a certain age) to renew and continue his or her health insurance policy by the timely payment of premiums.
HIPAA (Health Insurance Portability and Accountability Act of 1996): Legislation mandating specific privacy rules and practices for medical care providers and health insurance companies, designed to streamline the healthcare and insurance industries and to protect the privacy and identity of healthcare consumers. HIPAA also provides additional protections for consumers, designed to help them obtain or retain health insurance coverage in certain circumstances. For more information on HIPAA rules and regulations, visit the Centers for Medicare and Medicaid Services website at http://www.cms.hhs.gov.
HMO: HMO means "Health Maintenance Organization." HMO plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO, or who agree to provide services to members at a pre-negotiated rate. As a member of an HMO, you will need to choose a primary care physician ("PCP") who will provide most of your health care and refer you to HMO specialists as needed. Some HMO plans require that you fulfill a deductible before services are covered. Others only require you to make a copayment when services are rendered. Health care services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency.
An HMO may be right for you if:
- You're willing to play by the rules and coordinate your care through a primary care physician
- You're looking for comprehensive benefits at a reasonable monthly premium
- You value preventive care services: coverage for checkups, immunizations and similar services are often emphasized by HMOs
HSA (Health Savings Account): A tax advantaged savings account to be used in conjunction with certain high-deductible (low premium) health insurance plans to pay for qualifying medical expenses. Contributions may be made to the account on a tax-free basis. Funds remain in the account from year to year and may be invested at the discretion of the individual owning the account. Interest or investment returns accrue tax-free. Penalties may apply when funds are withdrawn to pay for anything other than qualifying medical expenses. Click here for more information on HSAs.
Health Care Financing Administration (HCFA): See the Centers for Medicare and Medicaid Services.
Health Service Agreement: An agreement between an employer and a health insurance company outlining benefits, enrollment procedures, eligibility standards, etc.
High Deductible Health Plan (HDHP): A type of health insurance plan that, compared to traditional health insurance plans, requires greater out-of-pocket spending, although premiums may be lower. In 2012, an HSA-qualifying HDHP must have a deductible of at least $1,200 for single coverage and $2,400 for family coverage. The plan must also limit the total amount of out-of-pocket cost-sharing for covered benefits each year to $6,050 for single coverage and $12,100 for families. In 2013, an HSA-qualifying HDHP must have a deductible of at least $1,250 for single coverage and $2,500 for family coverage. The plan must also limit the total amount of out-of-pocket cost-sharing for covered benefits each year to $6,250 for single coverage and $12,500 for families.
Home Health Agency: A certified healthcare agency that provides home health care services. See, Home Health Care.
Home Health Care: Part-time care that is provided by medical professionals in the home setting rather than in a hospital or skilled nursing facility.
Hospice Care: Care rendered either on an inpatient basis or in the home setting for a terminally ill patient. Often referred to as "palliative" or "supportive" care, hospice care emphasizes the management of pain and discomfort and the emotional support of the patient and family. See also, Respite Care.
Hospital Benefits: Benefits payable for hospital room and board and other miscellaneous charges resulting from hospitalization.
Hospitalization: Typically, hospitalization services include services related to staying at a hospital for either scheduled procedures, accidents or medical emergencies. Hospitalization services typically do not include hospital stays for giving birth to a child.
Hospitalization Insurance: Insurance intended to provide coverage in case of hospitalization, including benefits for room and board and miscellaneous expenses, within certain limitations.
IPA (Individual Practice Association): An organization of physicians who may maintain separate offices but who negotiate contracts with insurance companies and medical facilities as a group. Some health insurance applications will ask you to provide your primary care physician's IPA number. It can usually be found in the health insurance plan's online directory.
In-area Services: Healthcare services rendered within a health insurance plan's coverage area.
Incontestable Clause: A provision in an insurance policy that states that the validity of the insurance contract cannot be contested after two (or sometimes three) years.
Indemnity Plan: Also called "fee-for-service" plans, Indemnity plans typically allow you to direct your own health care and visit whatever doctors or hospitals you like. The insurance company then pays a set portion of your total charges. You may be required to pay for some services up front and then apply to the insurance company for reimbursement. Indemnity plans typically require that you fulfill an annual deductible. Because of the freedom they allow members, Indemnity plans are sometimes more expensive than other types of plans.
An Indemnity plan may be right for you if:
- You want the greatest level of freedom possible in choosing which doctors or hospitals to visit
- You don't mind coordinating the billing and reimbursement of your claims yourself
Individual and Family Health Insurance: A type of health insurance purchased by an individual or family, independent of any employer group or organization.
Infertility: Typically, infertility services include any medical services, both inpatient and outpatient, to assist with the conception of child.
Inpatient: A term used to describe a person admitted to a hospital for at least 24 hours. It may also be used to describe the care rendered in a hospital when the duration of the stay is at least 24 hours.
Integrated Delivery System: A group of doctors, hospitals and other providers who work together to deliver a broad range of healthcare services.
Intermediate Care: A level of nursing care, considered less intensive than skilled nursing care, but which may be rendered in a skilled nursing or intermediate care facility.
Lab/X-Ray: Typically, lab/x-ray is any diagnostic lab test or diagnostic/therapeutic x-ray performed in support of basic health services. Lab services typically include services like blood panels and urinalysis. X-ray services typically include basic outpatient skeletal or other plain film x-ray, outpatient ultrasound, GI series, MRI, and CT scan. Prostate cancer screening, mammograms, and pap smears may be covered by Lab/X-Ray benefit, or they may be covered by Periodic OB-GYN benefit or Preventative Care benefits. Typically, dental x-rays are not included in Lab/X-ray benefits.
Lapse: The termination of insurance coverage due to lack of payment after a specific period of time.
Length of Stay (LOS): The total number of days that a patient stays in a facility such as a hospital.
Lifetime Limit: Many health insurance plans place dollar limits upon the claims that the plan will pay over the course of an individual's life. PPACA prohibits lifetime limits on the dollar value of benefits deemed essential by the Department of Health and Human Services, for plan or policy years beginning on Sept. 23, 2010.
Lifetime Maximum: Lifetime maximum or lifetime limits refers to the maximum dollar amount that a health insurance company agrees to pay on behalf of a member for covered services during the course of his or her lifetime. For plan or policy years beginning on or after Sept. 23, 2010, plans may not establish any lifetime limit on the dollar amount of benefits for any individual. All plans are required by PPACA to remove the lifetime maximum restrictions.
Limitations: A term referring to any maximums that a health insurance plan imposes on specific benefits.
Long-term Care: Care provided on a continuing basis for the chronically ill or disabled. Long-term care may be provided on an inpatient basis (at a long-term care facility) or in the home setting.