Child Abuse

Child Abuse

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

Wellness Plan/Program

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.

Subscriber

Subscriber

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.

Specialist

Specialist

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.

Self-Funded

Self-Funded

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.

Risk Pool

Risk Pool

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.

Retrospective Review

Retrospective Review

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.

Reinsurance

Reinsurance

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

Rehabilitation Services

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.

Qualified Health Plan (QHP)

Qualified Health Plan (QHP)

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.

Premium

Premium

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)

Preferred Provider Organization (PPO)

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-Authorization

Pre-Authorization

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.

Point of Service (POS) Plan

Point of Service (POS) Plan

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.

Pharmacy and Therapeutics (P&T) Committee

Pharmacy and Therapeutics (P&T) Committee

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.

Out-of-Network-Provider

Out-of-Network-Provider

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

Open Enrollment

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.

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