Gatekeeper under some health insurance arrangements, a gatekeeper is responsible for the administration of the patients treatment. Adhesive contract a contract between two parties where one party with stronger bargaining power sets the terms and conditions and the other party, which is the weaker of the two with little to no ability to negotiate, must adhere to the contract and is placed in. Claim provisions rules for filing claims and for the claims appeals process. This limit never includes your premium, balance billed charges or health care your health insurance or plan doesnt cover.
Pdf knowledge of health insurance terminology and details. Glossary of health coverage and medical terms this glossary defines many commonly used terms, butisnt a full list. This limit generally does not include things like your premium or noncovered services. A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Agent the insurance company representative who sells policies on behalf of the insurer. Health insurance financial protection against all or part of. Primer on health insurance concepts and terminology. An individuals ability to obtain appropriate health care services. In the area of health insurance, it is the act of authorizing or affirming a service to a client that implies agreement to be responsible for reimbursing the provider of the service the related cost of providing the service to a clientsupport system. Actuaries the insurance professionals who perform the mathematical analysis necessary for setting. Read online glossary of insurance and medical billing terms book pdf free download link book now.
In the united states, this level is determined by the department of health and human services. Actuary a professional trained in the mathematics of insurance and risk management, including the calculations of. Health insurance glossary understanding healthcare terms. Glossary of medical insurance terminology ucsf student health. Costsharing all costs to the consumer beyond premiums, includes deductible, copays, and co insurance. A federal and statefunded health insurance program for. An independent agent represents more than one company. Think of an online mall, but where all the stores sell health coverage. Those can be found in your insurance policy or certificate. Vermont health benefit exchange august 21, 2012 glossary of insurance terms actuarial value the percentage of an average enrollees medical costs that an insurance provider is expected to cover.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Annual deductible is the amount you must pay each year for medical and mental health expenses before your medical plan begins to pay benefits. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan or health insurance. Glossary of insurance terms vermont health connect. Compare plans side by side, get health insurance quotes, apply online and find affordable health insurance today. Health insurance glossary understanding health care. Your guide to the affordable care act aca glossary of. Webmd provides definitions of terms related to health insurance, the affordable care act and medicare. If your provider charges more than the allowed amount, you may have to pay the. A contract that requires your health insurer to pay some or all of your health care costs in exchange. Habilitation services health care services that help a person keep, learn or improve skills and functioning for daily living. Assembly health committee 916 3192097 1 20 health glossary of terms access. This may be called eligible expense, payment allowance, or negotiated rate.
Glossary of health insurance and medical terms page 2 of 4 grievance a complaint that you communicate to your health insurer or plan. Also called an exchange, a health insurance marketplace is a place where you can buy health coverage online. Most had little or no experience with health insurance terminology. Insurance terminology north american training group. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan or health insurance policy.
These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. The plan must also limit the total amount of outofpocket cost. Health insurance glossary health insurance definitions. Medicare part b medical insurance helps cover doctor and other health care providers services, outpatient care, home health care, durable. All books are in clear copy here, and all files are secure so dont worry about it. Glossary of health coverage and medical terms omb control numbers 15452229, 12100147, and 09381146 page 1 of 6 glossary of health coverage and medical terms this glossary defines many commonly used terms, but isnt a full list.
Some health insurance or plans dont coun t all of your copayments, deductibles, coinsurance payments, out ofnetwork payments or other expenses. If you qualify for a tax credit or subsidy to help pay for your coverage, you must buy your health plan through the federal health insurance marketplace, located at healthcare. The discontinuance of an insurance policy before its normal expiration date, either by the insured or the company. Its purpose is to insure against the risk that any one claim will exceed a specific dollar amount or that an entire plans losses will exceed a specific amount. This is the share of the cost you pay for health care received after you meet your deductible. Glossary of health insurance terms national health policy forum. Glossary of medical insurance terminology page 1 annual deductible is the amount you must pay each year for medical and mental health expenses before your medical plan begins to pay benefits. Medicare part a hospital insurance helps cover inpatient care, skilled nursing facility care, hospice care, home health care.
On march 23, 2010, president obama signed the patient protection and affordable care act ppaca into. You can get a copy of the policy at or you may call. A copay is in addition to the amount your insurance pays for the service. A complaint that you communicate to your health insurer or plan. Health care services that help a person keep, learn or. The insurance contracts act allows an insurer to avoid. Habilitation services health care services that help a person keep, learn or. Coinsurance a form of medical cost sharing in a health insurance plan that requires an insured person to pay a. Glossary of health coverage and medical terms page 1 of 4 this glossary has many commonly used terms, but isnt a full list. Download glossary of insurance and medical billing terms book pdf free download link or read online here in pdf. These glossary terms and definitionsare intended to be educational and may be different from the terms and definitions in your plan or health insurance policy.
Health care services that your health insurance or plan doesnt pay for or cover. Adverse event any harm a patient suffers that is caused by factors other than the patients underlying condition. Glossary of insurance and medical billing terms pdf book. Assessmentone of public healths three core functions. Examples include therapy for a child who isnt walking or talking at the expected age. Glossary of health coverage and medical terms page 2 of 6 deductible an amount you could owe during a coverage period usually one year for covered health care services before your plan begins to pay.
The maximum amount of benefits a health insurance plan will pay over a persons lifetime. Glossary of health coverage and medical terms page 2 of 4 excluded services health care services that your health insurance or plan doesnt pay for or cover. Glossary of terms ehnac glossary of terms 10119 page 1 of 42. The federal poverty level fpl is the set minimum amount of. Understanding your explanation of benefits pdf document. Evidence has shown that the reading difficulty of health insurance plan documents. Glossary of health coverage and medical terms this glossary has many commonly used terms, but isnt a full list.
Glossary of insurance and medical billing terms n nc noncovered charge procedure is not covered by health plan. Glossary of health coverage and medical terms just plain clear. Glossary of medical insurance terminology pdf uc merced. Group insurance coverage through an employer or other entity that covers all individuals in the group. Patient financial services glossary of insurance terms created. If your plan has a 20% coinsurance, your insurance may pay 80% of the cost and you might pay 20%. Glossary of insurance and medical billing terms d deductible the amount an insured member must pay before the insurance company begins covering health care costs. Medical insurance glossary of terms health medicare pdfs. The most you pay in a year before your health insurance pays 100% of qualifying costs. Hipaa health insurance portability and accountability act of 1996 the federal law enacted in 1996 which eased the job lock problem by making it easier for individuals to move from job to job without the risk of being unable to obtain health insurance or having to wait for coverage due to.
Glossary of health insurance and medical terms this glossary has many commonly used terms, but it isnt a full list. Glossary of health insurance terms by rmhp in comparing and evaluating health plan options, the industry terminology can be a little overwhelming. An insurance plan thats certified by the health insurance marketplace, provides essential health benefits, follows established limits on costsharing like deductibles, copayments, and outofpocket maximum amounts, and meets other requirements under the affordable care act. A company owned solely or in large part by one or more non insurance entities. Subscribe to get email or text updates with important deadline reminders, useful tips, and other information about your health insurance. These limits put a cap on health care costs if you ever have a major illness or injury.
Dhs department of health care services for california. When making decisions about health coverage, consumers should know the specific meanings of terms used to. Other terms and more information are in your insurance policy or certificate. Your guide to the affordable care act aca glossary of aca. Glossary of health insurance and medical terms page 1 of 4 glossary of health insurance and medical terms this glossary has many commonly used terms, but it isnt a full list. When making decisions about health coverage, consumers should know the specific meanings of terms used to discuss health insurance. The insurance contracts act allows an insurer to avoid a policy ab initio in situations where an insured fraudulently non. If you dont have minimum essential coverage, you may have to pay a penalty when you file your federal income tax return unless you qualify for a health coverage. On march 23, 2010, president obama signed the patient protection and affordable care act ppaca into law. Medicare and health insurance terminology balance bill.
Consumer glossary national association of insurance. The plan must also limit the total amount of out of pocket cost. A form of corporation, allowed by the irs for most companies with 35 or fewer shareholders, which enables the company to enjoy the benefits of incorporation but be taxed as if. Some of these terms also might not have exactly the same meaning when. An overall deductible applies to all or almost all covered items and services. Childrens health insurance program chip health services for lowincome families with children who dont qualify for medicaid. For each plan offered, covered california shows the percentage of the cost that the insurance company is agreeing to cover. Glossary of insurance terms the az for insurance practitioners terms generally associated with reinsurance ab initio a term used to describe avoidance of a contract from its inception or its beginning. Npi national identification number standard unique 10digit identifier assigned to health care providers by cms. Glossary of health insurance terms health insurance for. Glossary of health insurance terms blue cross and blue shield of. Glossary of health coverage and medical terms page 1 of 6 glossary of health coverage and medical terms this glossary defines many commonly used terms, but isnt a full list. Uc ship health card logo 422 actuarial value the actuarial value of a plan represents the total covered costs that the insurance company expects to pay for someone enrolled in the plan.
Claim what your provider or pharmacy sends us for payment of a service, above any copayment or coinsurance you pay. Other medical insurance terms copay this is a predetermined flat fee that you pay for a specific health care service. These glossary terms and definitionsare intended to be educational and may be different from the terms and definitions in your plan. See if you qualify for a special enrollment period. Obtaining services from doctors within the health insurance plans network, called preferred providers, results in lower fees to participants. Affiliated provider a health care provider that is part of a network, usually having a formal. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. A company owned solely or in large part by one or more non insurance entities for the primary purpose of providing insurance. Medicare part b medical insurance helps cover doctor and other health care providers services, outpatient care, home health care, durable medical equipment wheelchairs, walkers, hospital beds. Any willing provider law laws that require managed care plans to contract with all appropriate health care providers that meet their terms and conditions. Definitions of health insurance terms in february 2002, the federal governments interdepartmental committee on employmentbased health insurance surveys approved the following set of definitions for use in federal surveys collecting employerbased health insurance data. But once you meet your outofpocket maximum, your insurance pays 100% of qualifying costs.
Barriers to access can be financial insufficient monetary resources, geographic distance to providers, organizational lack of available providers and sociological e. Health excessstop loss this type of insurance may be extended to either a health plan or a selfinsured employer plan. A marketplace where people can shop for and purchase health insurance online. Glossary of insurance terms actuary a professional trained in the mathematics of insurance and risk management, including the calculations of premiums, policy reserves and other values. Glossary of public health terms accreditationthe development of a set of standards, a process to measure health department performance against those standards, and some form of reward or recognition for those agencies meeting the standards. A federal and statefunded health insurance program for lowincome children, elderly, blind or disabled people. Health insurance glossary health insurance definitions and. Pdf by 2014, uninsured adults will be eligible for health insurance through. Those services actually covered by the insurance policy the amounts actually paid by the carrier billable services that are not covered by the insurance policy are exclusions. Health insurance glossary allowed amount maximum amount on which payment is based for covered healthcare services. Grievance a complaint that you communicate to your health insurer or plan.
840 223 1026 1197 792 473 35 366 449 438 333 214 525 1246 1353 586 447 1355 1502 219 1440 302 520 187 1404 1314 1143 928 738 57 360 1227 1456 1080 455 939 605