Child abuse or child maltreatment is physical, sexual, or psychological maltreatment or neglect of a child or children, especially by a parent or other caregiver. Child abuse may include any act or failure to act by a parent or other caregiver that results in actual or potential harm to a child, and can occur in […]
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.
Qualifying Event: An event that enables an individual to make a change to their health plan outside of the enrollment period. Examples include divorce, termination of employment, or birth of a child.
Qualified Health Plan (QHP): An insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like Deductibles, Copayments, and out-of-pocket maximum amounts), and meets other requirements. A QHP will have a certification by each Exchange in which it is sold.
Provider: A supplier of healthcare services like a hospital, nursing home, lab, or physician.
Primary Care Physician (PCP): A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.
Preventive Care: Care received to help prevent or detect illness before it occurs, such as routine physicals, well baby care, annual gynecological exams, etc.
Premium: The fee paid to a health insurance carrier by an enrolled company or individual, normally on a monthly basis, for the delivery and financing of healthcare services to the employees or the individual, and their dependents enrolled in the plan.
Preferred Provider Organization (PPO): A system in which a payer negotiates lower prices with certain doctors and hospitals. Patients who go to a preferred (or in-network) provider get a higher benefit-for example, 90 percent or 100 percent coverage of their costs-than patients who go outside the network
Pre-Existing Condition: A health condition (except pregnancy) that was diagnosed and/or treated within six months prior to enrolling in a health plan.
Pre-Authorization: The authorization required by an insurance carrier before the member is eligible to receive maximum benefits for hospitalization and other specific services. With some benefit plans, the member is responsible for obtaining pre-authorization prior to receiving services.
Pre-admission Review: Review of an elective hospitalization prior to a patient’s admission in order to ensure that the services are necessary and that they should be provided in an inpatient hospital setting.
Point of Service (POS) Plan: An HMO plan which allows the member to pay lower Copayment or Coinsurance if they stay within the established HMO delivery system, but permits member to choose and receive services from an outside doctor, any time, if they are willing to pay higher Copayments, Deductibles, and possibly monthly premiums.
Physician Services: Healthcare services a licensed medical physician (M.D.-Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Pharmacy and Therapeutics (P&T) Committee: A group of physicians, pharmacists, and other healthcare providers who advise a managed care plan regarding safe and effective use of medications. The P&T Committee manages the prescription drug formulary and acts as the organizational line of communication between the medical and pharmacy components of the health plan.
Per Diem Cost: Cost per day; hospital or other institutional cost for a day of care.
Patient Protection and Affordable Care Act (PPACA): A law with a series of statues that go into effect beginning March 23, 2010 aimed at increasing access to affordable healthcare for most Americans. Health insurers, healthcare facilities, physicians, individuals, small and large businesses, Medicare, and Medicaid are all impacted by the law.
Patient Centered Medical Home (PCMH): A team-based healthcare delivery model led by a physician that provides comprehensive and continuous medical care to patients. Some goals of a PCMH are better access to healthcare, increased satisfaction with care, and overall improved health.
Participating Provider: Any physician, hospital, pharmacy, laboratory, or other diagnostic centerunder contract with the health plan to provide services to members at a specified cost.
Outpatient Care: Care in a hospital that usually does not require an overnight stay.
Out-of-Pocket Maximum (OOP max or MOOP): The maximum amount that an insured person will have to pay for covered expenses under the plan, usually within the plan effective dates.
Out-of-Pocket Costs: Healthcare costs that are not covered by insurance, such as Copayments, Coinsurance, and Deductibles.
Out-of-Network-Provider (Non-Participating Provider): Any physician, hospital, pharmacy, laboratory, or other diagnostic center not under contract with a plan to provide services to members at a specified cost. In some benefit plans, members may have reduced coverage (or NO coverage if care is received from non-participating providers).
Open Enrollment: The period (usually once a year) during which subscribers in a health plan may have an opportunity to select an alternative plan being offered to them; or a period when uninsured employees and their dependents may obtain coverage.