Admitting Privileges
The right granted to a doctor to admit patients to a particular hospital.

Allowable Amount
The amount the insurance company determines is appropriate as payment to a provider for covered services.

Allowable Charge
The lesser of the actual charge, the customary charge, and the prevailing charge. It is the amount on which Medicare will base its Part B payment.

Ambulatory Care
Similar to outpatient treatment in that it is care which does not require hospitalization.

Ambulatory Setting
Institutions such as surgery centers, clinics, or other outpatient facilities which provide health care on an outpatient basis.

Ancillary
Additional services (other than room and board charges) such as X-rays, anesthesia, and lab work. This term may also be used to describe the charge made by a pharmacy for prescriptions which exceed the health insurance plan's maximum allowable cost.

Ancillary Benefits
Benefits for miscellaneous hospital charges.

Approved Charge
Amounts paid under Medicare as the maximum fee for a covered service.

Assignment of Benefits
A method where the person receiving the medical benefits assigns the payment of those benefits to a physician or hospital.

Return to Top

Board Certified
A physician or other professional who has passed an examination which certifies him or her as a specialist in a particular medical area.

Return to Top

Calendar Year Deductible
The dollar amount for covered services that must be paid during the calendar year (January 1 - December 31) by members before benefits are paid.

Capitation
In the strictest sense, a stipulated dollar amount established to cover the cost of health care delivered for a person. The term usually refers to a negotiated per capita rate to be paid periodically, usually monthly, to a health care provider. The provider is responsible for delivering or arranging for the delivery of all health services required by the covered person under the conditions of the provider contract.

Carry Over Provision (or Last Quarter Carryover)
In major medical policies, allowing an insured who has submitted no claims during the year to apply any medical expenses incurred in the last three months of the year toward the new calendar year's deductible.

Case Management
A system embraced by employers and insurance companies to ensure individuals receive appropriate, reasonable health care services.

Certificate Of Coverage
A description of the benefits included in a carrier's plan. The certificate of coverage is required by state laws and represents the coverage provided under the contract issued to the employer. The certificate is provided to the employee.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Part of the Uniformed Services Health Benefits Program which supplements the medical care available for families of active, deceased, and retired military personnel.

Claim
A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.

Coinsurance
Money an individual is required to pay for services, after a deductible has been met. In some health care plans, coinsurance is called "copayment." Coinsurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service while the employer or insurance company pays 80 percent.

Composite Rate
One rate for all members of the group regardless of their status as single or members of a family.

Comprehensive Major Medical
A plan of insurance which has a low deductible, high maximum benefits, and a coinsurance feature. It is a combination of basic coverage and major medical coverage which has virtually replaced separate hospital, surgical, and medical policies with each having its own deductible requirements (see Major Medical Insurance).

Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal law that, among other things, requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated (COBRA).

Continuation
Allows terminated employees to continue their group health insurance coverage under certain conditions

Coordination Of Benefits
A provision in a contract that applies when a person is covered under more than one group medical program. It requires that payment of benefits will be coordinated by all programs to eliminate over-insurance or duplication of benefits.

Copayment (or Copay)
This is an arrangement where the covered person pays a specified amount for various services and the health care provider pays the remainder. The covered person usually must pay his or her share when the service is rendered. Similar to coinsurance, except that coinsurance is usually a percentage of certain charges where the copayment is a dollar amount.

Copayment Maximum
The limit on the total amount that a member might have to pay in copayments during any one calendar year, after which the insurance company pays 100 percent of Allowed Charges up to specified benefit maximums. HMO, Preferred, and Non-Preferred Providers each carry different copayment maximum levels. See your Evidence of Coverage and Disclosure Form booklet for details.

Cosmetic Procedures
Procedures which improve the appearance, but are not medically necessary.

Custodial Care
Care that is primarily for meeting personal needs such as help in bathing, dressing, eating, or taking medicine. It can be provided by someone without professional medical skills or training but must be according to doctor's orders.

Return to Top

Date of Service
The date that the health service was provided.

Deductible
The amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.

Deductible Carryover Credit
During the last three months of a calendar year, charges incurred for health services can be used to satisfy the deductible for the following calendar year. These credits may be applied whether or not the prior calendar year's deductible had been met.

Dependent Coverage
Insurance coverage on the head of a family which is extended to his or her dependents, including only the lawful spouse and unmarried children who are not yet employed on a full-time basis. "Children" may be step, foster, and adopted, as well as natural. Certain age restrictions on children usually apply.

Detoxification
The process an individual goes through when withdrawing from alcohol. Usually is done under guidance of medical personnel.

Drug Formulary
A schedule of prescription drugs approved for use which will be covered by the plan and dispensed through participating pharmacies (Formularies).

Dual Choice
A term used to describe a situation in which only two carriers are contracted by a specific group. For example, an employer offers its employees one HMO and one indemnity plan, or two HMOs and no indemnity plan.

Durable Medical Equipment
Equipment which can stand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home. Examples of durable medical equipment include hospital beds, wheelchairs, and oxygen equipment.

Return to Top

ERISA
See Employee Retirement Income Security Act.

Elimination Period
A loosely used term, sometimes designating the probationary period, but most often designating the waiting period in a Health Insurance policy. See also Probationary Period and Waiting Period.

Emergency
An injury or disease which happens suddenly and requires treatment within 24 hours.

Emergency Accident Benefit
A group medical benefit which reimburses the insured for expenses incurred for emergency treatment of accidents.

Emergency Care
In an emergency, immediate medical attention is required to prevent death or disability due to a sudden trauma or illness such as a stroke or broken leg.

Employee Assistance Program (EAP)
Services designed to assist employees, their family members, and employers in finding solutions for workplace and personal problems. Services may include assistance for family/marital concerns, legal or financial problems, elder care, child care, substance abuse, emotional/stress issues, and other daily living concerns.

EAPs may address violence in the workplace, sexual harassment, dealing with troubled employees, transition in the workplace, and other events that increase the rate of absenteeism or employee turnover, lower productivity, and other issues that impact an employer's financial success or employee relations management. EAPs also can provide the voluntary or mandatory access to behavioral health benefits through an integrated behavioral health program.

Employee Contribution
The employee's share of the premium costs.

Employee Retirement Income Security Act of 1974, Public Law 93-406 (ERISA)
This law mandates reporting and disclosure requirements for group life and health plans.

Employer Contribution
The portion of the cost of a health insurance plan which is borne by the employer.

Evidence Of Insurability
Proof presented through written statements (e.g., an application form) and/or a medical examination that an individual is eligible for a certain type of insurance coverage. This form is required for eligibles who do not enroll during the open enrollment period (generally a 31-day period), or who apply for excess amounts of group life insurance. Also known as evidence of good health.

Exclusions
Medical services not covered by an individual's insurance policy.

Exclusive Provider Organization (EPO)
A term derived from the phrase preferred provider organization (PPO). However, where a PPO generally extends coverage for non-preferred provider services as well as preferred provider services, an EPO provides coverage only for contracted providers. Technically, many HMOs also can be described as EPOs.

Explanation of Benefits (EOB)
A detailed written description of provider charges and services that includes the insurance company and the member's payment responsibilities.

Extended Care Facility
A facility such as a nursing home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Three levels of care may be provided--skilled, intermediate, custodial, or any combination.

Extension of Benefits
A condition in the insurance policy which allows coverage to continue beyond the expiration date of the policy in the case of employees who are not actively at work or dependents who are hospitalized on that date. The extended coverage applies only where the employee or dependent is disabled as of that date and continues only until the employee returns to work or the dependent leaves the hospital.

Return to Top

Family/General Practice
Doctors who treat adult men and women as well as children.

Fee-For-Service Reimbursement
The traditional health care payment system, under which physicians and other providers receive a payment that does not exceed their billed charge for each unit of service provided.

Return to Top

Gatekeeper Model
Under this model of HMO and PPO organizations, the primary care physician (the gatekeeper) is the initial contact for the patient for medical care and for referrals. This is also called a closed access or closed panel.

Generic Drug
A drug which is exactly the same as a brand name drug and which is allowed to be produced after the brand name drug's patent has expired. It is also called a "generic equivalent" (Generic Drugs).

Return to Top

Health Care Financing Administration (HCFA)
Part of the Department of Health and Human Services, responsible for administration of the Medicare and Medicaid programs. The HCFA establishes standards for medical providers which must be complied with if the provider is to meet certification requirements.

Health Maintenance Organization (HMO)
An entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium. There are four basic models of HMOs: group model, individual practice association, network model, and staff model. Under the Federal HMO Act, an entity must have three characteristics to call itself an HMO:

1. an organized system for providing health care or otherwise assuring health care delivery in a geographic area.
2. an agreed upon set of basic and supplemental health maintenance and treatment services.
3. a voluntarily enrolled group of people. See also group model, individual practice association, network model, and staff model.

Home Health Care
Care received at home as part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services of home health aides or help from homemakers or choreworkers.

Hospice
An organization which is primarily designed to provide pain relief, symptom management and supportive services for the terminally ill and their families. Hospice care is covered under Part A of Medicare.

Return to Top

Indemnity Health Plan
Also called "fee-for-service," these plans primarily existed before the rise of HMOs, IPAs, and
PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services while the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals.

Independent Practice Association (IPA)
A group of physicians with individual offices who form an organization in order to contract, manage, and share financial responsibilities for providing health care services to health plan members.

Individual Practice Association Model HMO (IPA)
A health care model that contracts with an entity, which in turn contracts with physicians, to provide health care services in return for a negotiated fee. Physicians continue in their existing individual or group practices and are compensated on a per capita, fee schedule, or fee-for-service basis.

Internists
Doctors who treat men and women over age 18.

Return to Top

Large Claim Pooling
A system designed to help stabilize premium fluctuations in smaller groups. Large claims (those over a stated amount) are charged to a pool contributed to by many small groups who belong and share in that pool. The smaller the group of groups, the lower the pooling level. Larger groups will have a larger pooling level.

Living Benefits Rider
A rider attached to a life insurance policy which provides LTC benefits or benefits for the terminally ill. The benefits provided are derived from the available life insurance benefits.

Living Need Benefits
A combination of life insurance and long-term care insurance which allows life insurance benefits to generate long-term care benefits. Up to a certain percentage of the life insurance policy's death benefit may be used in advance to offset nursing home or medical expenses, reducing the face amount of the life policy.

Long Term Care (LTC)
Care which is provided for persons with chronic diseases or disabilities. The term includes a wide range of health and social services provided under the supervision of medical professionals.

Long Term Care Facility
Usually a state licensed facility which provides skilled nursing services, intermediate care, and custodial care.

Long Term Disability Insurance
A group or individual policy which provides coverage for longer than a short term, often until the insured reaches age 65 in the case of illness and for the remainder of his lifetime in the case of accident. See also Short Term Disability Insurance.

Long Term Care Policy
Insurance policies that cover specified services for a specified period of time. Long Term Care policies (and their prices) vary significantly. Covered services often include nursing care, home health care services, and custodial care.

Return to Top

Major Medical Insurance
A type of health insurance that provides benefits up to a high limit for most types of medical expenses incurred, subject to a large deductible. Such contracts may contain limits on specific types of charges, like room and board, and a percentage participation clause sometimes called a coinsurance clause. These policies usually pay covered expenses whether an individual is in or out of the hospital.

Managed Care
A system of health care where the goal is a system that delivers quality, cost effective health care through monitoring and recommending utilization of services, and cost of services.

Managed Health Care Plan
A plan which involves financing, managing, and delivery of health care services. Typically, it involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost effective, but quality, service.

Mandated Benefits
Benefits required by state or federal law.

Maximum Dollar Limit
The maximum amount of money an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.

Maximum Out-of-Pocket Costs
The most a member will pay considering copayments, coinsurance, deductibles, and the like.

Medicaid
A medical benefits program administered by states and subsidized by the federal government. Under this plan, various medical expenses will be paid to those who qualify. It is technically referred to as Title XIX Benefits.

Medical Group
An organization of physicians who are generally located in the same facility and provide a range of health care services to health plan members.

Medical Information Bureau (MIB)
A data pool service that stores coded information on the health histories of persons who have applied for insurance from subscribing companies in the past. Most Life and Health insurers subscribe to this bureau to get more complete underwriting information.

Medical Loss Ratio
Total health benefits divided by total premium.

Medical Savings Account (MSA)
A tax-advantaged personal savings or investment account intended for medical services, including some not covered by your health plan. MSA contributions are deductible from gross income for tax purposes (whether or not you itemize deductions). MSA funds can be used tax-free for qualified medical expenses or saved on a tax-deferred basis for the future.

Medical Supplies
Any items which are essential in carrying out the treatment of a patient's illness or injury.

Medically Necessary
A service or treatment which is absolutely necessary in treating a patient and which could adversely affect the patient's condition if it were omitted.

Medicare
The United States federal government plan for paying certain hospital and medical expenses for persons qualifying under the plan, usually those over 65. The hospital benefits are Part A, and the medical expense portion is Part B. Part A is compulsory social insurance; Part B is voluntary government-subsidized, government-operated insurance.

Medicare Beneficiary
Anyone entitled to Medicare benefits based on the designation by the Social Security Administration.

Medicare Supplement Insurance
Insurance coverage sold on an individual or group basis which helps to fill the gaps in the protection provided by the Medicare program. Medicare supplements cannot duplicate any benefits provided by Medicare, but may pay part or all of Medicare's deductibles and copayments, and may cover some services and expenses not covered by Medicare.

Minimum Premium
A cost plus arrangement whereby the employer pays the insurer only a portion of the premium which is to be used for administration costs. The remainder is placed in a "bank account" which is then used by the insurer to pay claims.

Miscellaneous Expenses
Ancillary expenses, usually hospital charges other than daily room and board. Examples would be X-rays, drugs, and lab fees. The total amount of such charges that will be reimbursed is limited in most basic hospitalization policies.

Multiple Employer Trust (MET)
A trust consisting of multiple small employers in the same industry, which is formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than would be available to the employers individually.

Return to Top

Noncancellable (Non-Can)
A contract of Health Insurance that the insured has a right to continue in force by payment of premiums, as set forth in the contract, for a substantial period of time, also as set forth in the contract. During that period of time, the insurer has no right to make any change in any provision of the contract. The NAIC recommends that the term "noncancellable" not be permitted to be used to designate any form that is not renewable to at least age 50 or for at least five years if issued after age 44. Note that this is in contrast to Guaranteed Renewable, on which the premium may be increased by classes. The premium for noncancellable policies must remain as stated in the policy at the time of issue. Contrast with Guaranteed Renewable.

Nonduplication of Benefits
A provision in some Health Insurance policies specifying that benefits will not be paid for amounts reimbursed by others. In Group Insurance, this is usually called Coordination of Benefits.

Non-participating Provider
A term used to describe a provider that has not contracted with the carrier or health plan to be a participating provider of health care. Non-Preferred Provider A physician, hospital or other health care provider not under contract with the insurance company and not a designated member of the insurance company's Preferred Provider Network.

Nursing Home
A licensed facility which provides general nursing care to those who are chronically ill or unable to take care of necessary daily living needs. May also be referred to as a Long Term Care facility.

Return to Top

Obstetricians/Gynecologists
Doctors who treat adult women and teenage girls.

Open Access
A self-referral arrangement allowing members to see participating providers for specialty care without a referral from another doctor. Typically found in an IPA HMO. Also called Open Panel.

Open Enrollment Period
A period during which members can elect to come under an alternate plan, usually without providing evidence of insurability.

Out-Of-Area
Coverage for treatment obtained by a covered person outside the network service area.

Out-Of-Pocket Costs/Expenses
The portion of payments for health services required to be paid by the enrollee, including copayments, coinsurance, and deductibles.

Out-of-Network
Physicians, hospitals, or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-network health professionals may not be covered or may be covered only in part.

Out-of-Pocket Maximum
A predetermined limited amount of money an individual must pay out of their own pocket before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.

Outpatient
An individual (patient) who receives health care services (such as surgery) without an overnight stay in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. "Outpatient" is also used synonymously with "ambulatory" to describe health care facilities where procedures are performed.

Over-The-Counter Drug
A drug product that does not require a prescription under federal or state law.

Return to Top

Participating Provider
A provider who has contracted with the health plan to deliver medical services to covered persons. The provider may be a hospital, pharmacy, or other facility or a physician who has contractually accepted the terms and conditions as set forth by the health plan.

Pediatricians
Doctors who treat boys and girls up to age 18.

Personal Physician/Primary Care Physician
A family/general practitioner, internist, obstetrician/gynecologist, or pediatrician who has contracted with the HMO to provide primary care to plan members and to refer, authorize, supervise, and coordinate all health care services in accordance with their contract with the insurance company.

Physical Therapist
A trained medical person who provides rehabilitative services and therapy to help restore bodily functions such as walking, speech, the use of limbs, etc.

Point-of-Service (POS)
A health plan that gives covered members several options for accessing care. Members may receive covered services from participating or non-participating providers. Members' cost depend on which option they choose and who provides their care. Point-of-service coverage can be provided as follows:

1. An HMO may allow members to obtain limited services from non-participating providers
2. An HMO may provide non-participating benefits through a supplemental major medical policy
3. A PPO may be used to provide both participating and non-participating levels for coverage and access

Pre-Admission Authorization
A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization and receive authorization for the admission.

Pre-Admission Certification
A review of the need for inpatient hospital care, done prior to the actual admission. Established review criteria are used to determine the appropriateness of inpatient care.

Pre-Admission Testing
Medical tests completed for an individual prior to being admitted to a hospital or inpatient health care facility.

Preferred Provider
A physician, hospital, or other health care provider under contract with the insurance company and designated as a member of the provider network. Preferred Providers agree to furnish health care services to plan subscribers and accept the insurance company's allowable amount as payment in full, usually after a copayment.

Preferred Provider Organization (PPO)
A health plan in which contracts are established with providers of medical care. These providers are called preferred providers. Preferred providers contractually agree to provide PPO plan subscribers covered services for a set copayment amount. This encourages plan subscribers to use these providers. Covered subscribers may also seek services from a non-preferred provider often with significant copayments.

Pre-Existing Condition
Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage under the master group contract.

Prescription Medication
A drug which can be dispensed only by prescription and which has been approved by the Food and Drug Administration.

Preventive Care
This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur.

Primary Care
Basic health care provided by doctors who are in the practice of family care, pediatrics, and internal medicine.

Primary Care Network
A group of primary care physicians who have joined together to share the risk of providing care to their patients who are covered by a given health plan.

Primary Care Physician (PCP)
A physician the majority of whose practice is devoted to internal medicine, family/general practice, and pediatrics. An obstetrician/gynecologist may be considered a primary care physician.

Primary Coverage
This is the coverage which pays expenses first, without consideration whether or not there is any other coverage. See also Coordination of Benefits.

Prior Authorization
A cost containment measure which provides full payment of health benefits only when the hospitalization or medical treatment has been approved in advance.

Probationary Period
A period of time between the effective date of a Health Insurance policy, and the date coverage begins for all or certain physical conditions.

Provider
Health care professionals that provide health care services, such as physicians, hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.

Return to Top

Qualifying Event
An occurrence (such as death, termination of employment, divorce, etc.) that triggers an insured's protection under COBRA, which requires continuation of benefits under a group insurance plan for former employees and their families who would otherwise lose health care coverage (COBRA).

Quality Assurance
A formal set of activities to review and affect the quality of services provided. Quality assurance includes quality assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative, and support services.

Return to Top

Reasonable and Customary (R&C)
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community.

Referral
Occurs when a physician or other health plan provider receives permission to consult another physician or hospital.

Referral Provider
The person or provider to whom a participating provider has referred a member of the plan.

Registered Nurse (RN)
A licensed professional with a four-year nursing degree. Able to provide all levels of nursing care including the administration of medication.

Resource Based Relative Value Scale (RBRVS)
A fee schedule introduced by HCFA to reimburse physicians' Medicare fees based on the amount of time and resources expended in treating patients, with adjustments for overhead costs and geographical differences.

Return to Top

Second Surgical Opinion
A cost containment technique to help patients and insurance companies determine whether a recommended procedure is necessary, or whether an alternative method of treatment could accomplish the same result. Some health policies require a second surgical opinion before specified procedures will be covered, and many policies pay for the second opinion.

Secondary Care
Medical services provided by physicians who do not have first contact with patients. Examples would be specialists such as urologists, cardiologists, etc. (see also Primary Care).

Secondary Coverage
Coverage which provides payment for charges not covered by the primary policy or plan (see also Coordination of Benefits).

Section 125 Plan
A plan which provides flexible benefits. This plan qualifies under the IRS code which allows employee contributions to meet with pre-tax dollars.

Self-Funded Plan
Plan of insurance where an employer, which has fairly predictable claim costs, pays the claims rather than an insurance company.

Service Area
The area, allowed by state agencies or by the certification of authority, in which a health plan can provide services.

Short Term Disability
An injury or illness that keeps a person from working for a short time. The definition of short term disability (and the time period during which coverage extends) differs among insurance companies and employers. Short term disability insurance coverage is designed to protect an individual's full or partial wages during a time of nonwork-related injury or illness that prohibits the individual from working.

Short Term Disability Income Policy
A disability income policy with benefits payable for "short term," usually less than two years, as opposed to a Long Term Disability Income policy.

Short Term Disability Insurance
A group or individual policy usually written to cover disabilities of 13 or 26 weeks duration, though coverage for as long as two years is not uncommon. Contrast with Long Term Disability Insurance.

Skilled Nursing Care
Daily nursing and rehabilitative care that is performed only by or under the supervision of skilled professional or technical personnel. Skilled care includes administering medication, medical diagnosis and minor surgery.

Skilled Nursing Facility
A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in a hospital. Included is treatment for rehabilitation and other care such as 24-hour nursing coverage, physical, occupational, and speech therapies, etc.

Small Group Pooling
The combining into one pool of several small group business--used especially for computing more accurate premium rates for members of the pool.

Staff Model HMO
This is an HMO where physicians are employed and all premiums are paid to the HMO, which then compensates the physicians on a salary and bonus arrangement.

Summary Plan Description (SPD)
A description of the entire benefits package available to an employee as required to be given to persons covered by self-funded plans.

Return to Top

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
This act defines the primary and secondary coverage responsibilities of the Medicare program and also the provisions to be used by health plans in their contracts with the HCFA (Health Care Financing Administration).

Terminally Ill
A term which refers to the status of a person who will normally die within 6 months of a specific illness or sickness. Often refers to the terminally ill requirement for hospice care.

Third Party Administrator (TPA)
An independent person or corporate entity (third party) that administers group benefits, claims, and administration for a self-insured company/group. A TPA does not underwrite the risk.

Total Disability
A degree of disability from injury or sickness that prevents the insured from performing the duties of any occupation from remuneration or profit. The definition in any given case depends on the wording in a covering policy.

Triple Option Plan
Insurance plans offering three options from which an individual may choose: Traditional Indemnity, HMO, and PPO.

Return to Top

Urgent Care
An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as high fever or persistent diarrhea.

Usual, Customary, and Reasonable (UCR)
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. Also called reasonable and customary.

Utilization
This refers to how much a covered group uses a particular health plan or program.

Utilization and Review Committee
A committee composed of medical personnel whose purpose it is to monitor the health care services and supplies provided to Medicare patients.

Utilization Management
This procedure or process utilizes a review coordinator to evaluate the necessity and appropriateness of various health care services.

Utilization Review
A formal assessment of the medical necessity, efficiency, and/or appropriateness of health care services and treatment plans on a prospective, concurrent, or retrospective basis.

Return to Top

Vision Care Coverage
A health care plan usually offered only on a group basis which covers routine eye examinations, and which may cover all or part of the cost of eyeglasses and lenses.

Return to Top

Waiting Period
The period of time when you are not covered by insurance for a particular problem.

The answers are provided for your general information. Although we make every effort to insure accuracy in the information provided, we cannot make any guarantees as to this accuracy. We urge you to consult your lawyer, accountant or tax advisor for specific legal or tax advice.