Health Insurance Dictionary by Selected Benefits of Houston
Confused About A Term?
Admitting Privilege: The doctors’ right to admit his or her patients to a specific hospital or other treatment facility.
Benefit: The amount due from the Texas health insurance company to the insured, his/her assignee or beneficiary when an person suffers a medical loss from a covered expense.
Case Management: A structure used by insurance carriers and employers to help ensure that& their members or employees receive adequate medical care.
Claim: A claim is a request by an insured (or his/her medical provider) to their health insurer for the insurance company to pay for medical care obtained from a doctor, hospital or any other medical professional..
Co insurance: Co insurance is an expense that an insured person is required to pay for medical services, after their deductible is met. Co insurance is often expressed as a percentage. In other words, the insured is responsible for 20% of the covered expenses for a medical service and the Texas health insurance carrier pays 80% up to the coinsurance limit.
Co payment: A Co payment or "co pay" is a predetermined dollar amount that a person will be responsible for at the time health care is rendered. This is normally in addition to what the Texas health insurance policy covers as outlined in the policy. As an example, some PPOs require a $30 co pay for each doctor office visit. Co pays are always expressed as a fixed dollar amount and not as a percentage.
Deductible: A deductible is the amount an insured is responsible for before the health insurance policy will cover the medical expense. Health insurance polices in Texas are normally based on calendar year deductible.
Denial Of Claim: A health insurance company may refuse to pay for certain medical expenses which are not covered by the insured’s' medical insurance policy.
Dependent Worker: A wage earner in a family where someone else has a higher level of income.
Employee Assistance Program: Counseling services (referred to as an "EAP") for mental health offered by health insurance companies or even some employers. Individuals don't typically have to pay for such counseling services provided through an EAP.
Exclusions: Medical expenses not covered by a persons' Texas health insurance policy.
Health Maintenance Organizations: Health Maintenance Organizations (HMOs) represent a prepaid insurance benefit plan in which a covered person or their employer pay a set fee (normally monthly) for medical services instead of a charge each time the insured has a medical visit or medical service. The fees are normally set and will not change, no matter the level of medical service provided. All medical services are completed by doctors who are employed by the HMO.
Indemnity Health Plans: Health insurance policies classified as indemnities are also called fee for service. These plans mostly existed before the creation of HMOs, IPAs and PPOs. In indemnity health insurance plans, the insured pays a predetermined portion of the cost of his or her medical care and the Texas health insurance company is responsible for the reminder. An insured might pay 25% for his medical service and the insurance company will be responsible for the remaining 75%. These "fee for services" are defined by the doctors and hospitals and will vary from doctor to doctor. Indemnity health insurance plans let individuals choose any health care professional they wish to see without restriction.
Independent Practice Association: Normally referred to as an “IPA”, these are very similar in design to an HMO, except that& covered persons receive medical care in a doctors' office. With an HMO, care is normally administered inside the HMO facility.
Long-Term Care Insurance Policy: A policy that covers specific services for a particular length of time. Covered medical services include nursing and custodial care along with home health care services.
LOS: An acronym referring to length of stay. It is a term used by Texas health insurance companies, an insured’s' case manager and ;an employer to describe the length of time period an individual is confined to a hospital or inpatient care facility.
Managed Care System: A system for delivering medical care that tries to manage the quality and expense of services that an insured will receive. Managed care systems offer only an HMO or PPO that the insured’s are instructed to use for their medical care services. Most of your better managed care policies have a goal to improve the quality of health by placing an emphasis on disease prevention.
Maximum Dollar Limit: Sometimes referred to as the Lifetime maximum, is the maximum amount of payout that a Texas health insurance company will pay for covered claims. Certain dollar limits can be based on specific types of medical conditions or medical services.
Medigap Insurance: Insurance policies offered by private Texas health insurance companies and are not at all similar to Medicare or Medicaid. Medigap policies are designed to cover many of the expenses that Medicare will not cover.
Open-ended HMOs: Will allow their insured clients to use out-of-plan providers (or out of network) and still receive partial or full reimbursement for the covered medical services under an indemnity policy.
Out of plan: Also called out of network. Refers to medical practitioners, hospitals, etc who are not considered participating providers in an insurance policy. Medical expenses from services provided by out of network medical professionals may not be covered as outlined in the policy or only partially covered by an individual's Texas health insurance company.
Out Of Pocket Maximum: A pre-determined limited amount of responsibility that an insured must pay before a Texas health insurance carrier will cover 100% for the insured’s medical care expenses.
Outpatient: An person who receives medical care services (such as a gallbladder surgery) on an outpatient care basis This means that they don't stay overnight in an in-network hospital or in-network inpatient treatment facility. Most health insurance companies have a list of tests, procedures and surgeries that won't be covered under a policy unless performed on an outpatient basis.
Pre Admission Review or Certification: Requires approval by an insured’s case manager or health insurance company rep for an insured to be admitted to the hospital or facility. This is always granted prior to admittance. The insured will often obtain an actual pre admission certification. The ultimate goal of the pre admission certification process is to ensure that people avoid exposure to medical care services that are not necessary.
Pre Admission Review: Review of an insured's health condition prior to being admitted to a hospital or inpatient facility. Pre admission reviews are normally conducted by case managers or insurance company reps, in conjunction with the insured, their doctor and any other provider which may be involved.
Pre admission Testing: Certain medical tests which are done before an insured is admitted to a hospital.
Pre existing medical condition: A medical issue that is excluded from an insured’s Texas health insurance policy by their insurance company normally since the medical condition existed prior to the individual's effective date of their health insurance policy.
Preferred Provider Organization: Also called PPOs. You will receive discounted or contracted rates if you use in network doctors or hospitals. Generally, if you see a doctor outside of the PPO network, you will pay more money for the same medical service.
Primary Care Provider (PCP): A medical care doctor whose responsibility it is to monitor an insured's overall medical care needs.
Provider: A provider is a medical professional who provides medical services. The term can refer to any health care professional such as a hospital, nurse practitioner, chiropractor, doctor, physical therapist and other person offering medical care services.
Reasonable and Customary: The average fee billed by a medical care practitioner within spercific geographic areas. Texas health insurance companies deem this ;as the total amount of money they will approve for a specific surgery, test or procedure. If the fee charged is higher than the reasonable and customary amount, the insured receiving the medical service is generally responsible for paying the difference. If an individual questions the amount charged by their physician, the provider will sometimes reduce the charges to the amount that the insureds' health insurance company has set as reasonable and customary.
Waiting Period: A period of time when your Texas health insurance policy will not cover you for a particular medical condition.