Wellness Plan/Program: An employer-sponsored program that can be part of the overall health plan or a separate program. Wellness programs aim to improve health and prevent disease while reducing overall healthcare costs, maintaining/improving employee health, and reducing illness-related absenteeism.
Usual, Customary, and Reasonable (UCR) Charges: The maximum amount an insurer will consider eligible for reimbursement under group health insurance plans. Charges are generally based on customary fees paid to providers with similar training and experience in a given geographic area.
Urgent Care: Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Third-Party Administrator (TPA): An organization that administers healthcare benefits, mostly for self-insured employers. Services may include claims review and claims processing.
Tertiary Care: Medical care requiring a setting outside of the routine, community standard; care to be provided within a regional medical center having comprehensive training, specialists, and research training.
Subscriber: An individual who meets the health plans’ eligibility requirement; who enrolls in the health plan; and accepts the financial responsibility for any premiums, Copayments, Coinsurance, or Deductibles.
Advanced Premium Tax Credit or Cost-Sharing Reduction
Specialist: A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of healthcare.
Small Business Health Options Program (SHOP): The portion of the Exchange dedicated to small businesses with 2-50 employees. Businesses with 51-100 employees will be eligible to participate in the SHOP beginning January 1, 2016.
Skilled Nursing Care: Services from licensed nurses in your home or in a nursing home. Skilled care services are from technicians and therapists in your home or in a nursing home.
Service Area: The geographic area served by an insurer or healthcare provider.
Self-Funded: A completely non-insured or self-funded plan is one in which no insurance company or insurance plan collect premiums and assumes financial risk. Employer groups use self-funded plans where they collect premiums from employees and pay the claims, but contract with an insurer to provide the administrative services.
Rollover: deductibles paid under a previous plan that are applied to the deductibles of the current plan.
Risk Pool: A financial arrangement that spreads the risk of utilization and cost among the participants generally the insurer, the hospitals, and the physicians. The pool may insure against unusually high utilization and costs. The pool may also provide incentives for controlling utilization and costs.
Risk: The possibility that costs associated with insuring a particular group will exceed expected levels, thereby resulting in losses for an insurance carrier or self-insurer.
Retrospective Review: The process where Emergency Room and Urgent Care Center claims and their supporting documentation is reviewed by the clinical department to determine the plan’s liability for payment based on the member’s type of insurance product.
Rescission of Coverage: A health plan is voided by the insurer, and the subscriber (member) could be responsible for any medical claims made against the health plan. Recession of coverage is prohibited except in cases of fraud.
Reinsurance: Insurance obtained by a carrier from another company to protect itself against part or all the losses incurred in the process of honoring the claims of members or policyholders. Also referred to as “stop loss” insurance. The coverage may apply to an individual claim or to all claims during a specified period for an individual […]
Rehabilitation Services: Healthcare services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Reconstructive Surgery: Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.