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What type of Health Insurance do you need?  A Glossary of Terms

To get the most from a health care plans,  it is important to understand the terms and phrases used by those providing health care coverage- the insurance  companies and your physician.

Admitting Privileges: The ability of a doctor  to admit a patient to a particular hospital.

Advocacy: Any activity done to help a person or  group get something the person or group wants or needs.

Assignment of Benefits: When you assign  benefits, you sign a document allowing your hospital or doctor to collect your health insurance benefits directly  from your health carrier. Otherwise, you pay for the treatment and then the company reimburses you.

Association: A group of individuals or  employers or combination thereof.

Capitation: Capitation represents a set dollar limit that your health maintanence organization (HMO) pays to your primary care physician for providing medical  treatment to you and your dependents. This fee is usually  paid to the physician on a monthly basis. The physician gets no more nor no less than this set fee no matter how  much you use his or her services.

Case Management: Case management is a system  that insurance companies and HMO's use to ensure that individuals receive appropriate, timely, and reasonable  health care services.

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

Co-insurance: Co-insurance refers to money that  an individual is required to pay for services, after a  deductible has been paid. In some health plans, coinsurance is called a "copayment."  Co-insurance is often specified by a percentage. For  example, the employee pays 20% toward the charges for a service and the employer or insurance company pays 80%.

Copayment: Co-payment is a predetermined fee  that an individual pays for health care services, in  addition to what the insurance covers. For example, some  HMOs require a $10 "co-payment" for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.

Deductible: The amount an individual must pay  for health care services before insurance covers any of  the costs. Deductibles are most frequently charged on an  annual basis rather than on a per incident basis.

Denial of a Claim: Refusal by an insurance  company to pay a claim submitted to them on behalf of an insured individual by a health care provider.

Employee Assistance Programs (EAPs): Mental health counseling services that are sometimes offered by insurance companies or employers. Typically, individuals or employers do not have to directly pay for services provided through an employee assistance program.

Exclusions and Limitations: Medical services that are either not covered or limited in benefit by an  individual's insurance policy.

Guaranteed Issue: An insurance company or HMO  will issue coverage to an applicant regardless of prior  medical history. In California, small employers (defined  as 3 to 50 employees) cannot be refused coverage for their employees regardless of the medical history of one or more employees.

Health Maintenance Organizations (HMOs): Health Maintenance Organizations represent "pre-paid" or "capitated" health care plans in which  individuals pay small fees or copayments for specified health care services over and above the monthly premiums paid to be a member of the HMO. Services are provided by physicians and allied health care personnel who are employed by, or under contract with the HMO. HMOs vary in design. Depending on the type of HMO, services may be  provided in a central facility, or in an individual  physicians office. HMO's are available on both an individual and employer group basis.

Indemnity Health Plan: Indemnity health insurance plans are also called  "fee-for-service." These are the types of plans  that primarily existed before the rise of HMOs, IPAs and PPOs. With indemnity plans, the individual pays a  predetermined percentage of the cost of health care  services, and the insurance company pays the additional percentage ultimately adding up to 100% of charges. For  example, an individual might pay 20% for services and the  insurance company pays 80%. The fees for services are defined by the providers and vary from physician to  physician. Indemnity health plans offer individuals the freedom to choose any physician or hospital.

Independent Practice Associations: A group of independent practicing physicians who band together for  the purpose of contracting their services to HMOs, PPOs and insurance companies.

Long Term Care Policy: Insurance policies that  cover the costs of providing nursing care, home health  care services and custodial care for the aged and infirmed.

Managed Care: The system that HMOs, PPOs and indemnity plan uses to provide quality health care while  controlling the costs of medical services that  individuals receive.

Maximum Dollar Limit: The maximum amount of  money that an insurance company will pay for claims  within a specific period of time. For instance, most PPO  types of programs have an overall lifetime maximum  expressed in millions of dollars (usually a minimum of $1M). Maximum dollar limits vary greatly. They may be  based on the type of illness or expressed in a period of  time.

Medically Necessary: Many insurance policies will pay only for treatment that is deemed "medically necessary" to restore a persons health. For instance, many policies will not cover  routine physical exams or plastic surgery for cosmetic  purposes.

Medigap Insurance Policies: Medigap insurance  is offered by private insurance companies, not the government. It is not the same as Medicare or Medicaid.  These policies are designed to pay for some of the costs that Medicare does not cover.

Open-ended HMOs: HMOs which allow enrolled  individuals to use out-of-plan providers and still  receive partial or full coverage and payment for the  professional's services under a traditional indemnity plan. These type of plans are also known as Point of Service Programs.

Out-Of-Plan: This phrase usually refers to  physicians, hospitals or other health care providers who  do not contract with the insurance plan (usually HMOs and PPOs). Depending upon the insurance plan, expenses  incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part  by an individual's insurance company.

Out-Of-Pocket Maximum: A predetermined limited  amount of money that an individual must pay out of pocket, before an insurance company will pay 100% for an individual's health care expenses.

Pre-Admission Certification: Also called  pre-certification review, or pre-admission review. This is approval by a case manager or insurance company representative for a person to be admitted to a hospital  or in-patient facility in advance of their admission. Usually, the patient's physician requests that this  process be completed. The goal of pre-admission  certification is to ensure that individuals are not hospitalized for unnecessary surgical procedures or services that are not medically necessary.

Pre-Existing Medical Conditions: Any illness or health problem that existed prior to an individual  obtaining medical coverage. Group health plans will cover pre-existing conditions after you have been covered for at least six months; individual plans after 12 months.

Preferred Provider Organizations (PPOs): This is a group of health care providers who have agreed by contract to furnish medical services to members of a health plan at discounted rates.

Primary Care Provider (PCP): A health care  professional who is responsible for monitoring an  individual's overall health care needs. Typically, a PCP  serves as a "gatekeeper" for an individual's medical care, referring the individual to specialists and  admitting them to hospitals when needed.

Reasonable and Customary Charges: The charges  that a carrier determines normal for a particular medical procedure in a specific geographic area. If charges are  higher than what the carrier considers normal, the  carrier will not pay the full amount charges and the  balance is the responsibility of the insured.

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

Waiver: A rider or amendment to a policy that  restricts benefits by excluding certain medical  conditions from coverage.

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