| - A - |
| Adjustment: |
The addition or removal of dependents from a subscriber's active policy. |
| Anniversary Date: |
The date on which a policy with an insurance carrier renews, and on which rates are subject to change. This date coincides with the beginning of the open enrollment period. |
| - B - |
| Benefit Booklet: |
An insurance carrier's prepared document explaining covered benefits, limitations, and exclusions. Also known as Certificate of Coverage, Evidence of Coverage, or Members' Handbook.
|
| Benefit Level: |
The limit or degree of coverage a subscriber is entitled to receive. |
| Benefit Period: |
Maximum length of time that insurance benefits will be paid for any one accident, illness or hospital stay. |
| Broker: |
A licensed insurance representative who does not represent a specific company, but places business among various companies. Legally, the broker is usually regarded as a representative of the insured rather than the company. |
| - C - |
| Carrier: |
Another term for insurer or entity responsible for the payment of benefits under an insurance policy; i.e., an insurer "carries" the risk for a policyowner.
|
| Company Number: |
An 11-digit number assigned by Small Business Service Bureau, Inc. to each small employer member. |
| Contract: |
An agreement enforceable by law, whereby one party binds itself to certain promises or deeds. |
| Contributory Plan: |
Group insurance issued to an employer, under which both the employer and employee contribute to the cost of the plan. |
| Conversion Privilege: |
Allows the policy owner, in the event the original insurance policy expires, to elect to have a new policy issued that will continue the insurance coverage. |
| Coordination of Benefits (COB): |
Designed to prevent duplication of group insurance benefits. Limits benefits from multiple group health insurance policies in a particular case to 100 percent of the expenses covered and designates the order in which the multiple carriers are to pay benefits. |
| Coverage Tier: |
Type of policy (i.e., individual, two-person or family). Structure is defined as 2-Tier consisting of rating for individual and family coverage; or 3-Tier, consisting of rating for individual, two-person and family coverage. |
| - D - |
| Deductible: |
Amount of expense or loss to be paid by the insured before a health insurance policy starts paying benefits. |
| Dependent: |
Legal spouse or children by birth, adoption, or legal guardianship that are eligible for coverage under a subscriber's policy in accordance with the carrier's established guidelines. |
| - E - |
| Effective Date: |
The date coverage is to start for a health, dental or life policy. |
| Enrollment Period: |
Period during which new employees can apply for coverage under a group insurance plan. |
| Errors and Omissions Insurance: |
Professional liability insurance that protects an insurance producer against claims arising from a service he or she rendered or failed to render. |
| Exclusions: |
Specified hazards listed in a policy for which benefits will not be paid. |
| - F - |
| - G - |
| Group Insurance: |
Insurance that provides coverage for a group of persons, usually employees of a company, under one master contract. |
| - H - |
| Health Maintenance Organization (HMO): |
An organization that provides comprehensive health care to voluntarily enrolled individuals and families in a particular geographic area by member physicians with limited referral to outside specialists and that is financed by fixed periodic payments determined in advance. |
| - I - |
| Identification Number (ID): |
An insurance carrier assigned number used to identify a subscriber and their dependents. |
| - J - |
| - K - |
| - L - |
| - M - |
| Medicare: |
A Federal program of health care coverage for the elderly, disabled and persons with End-Stage Renal Disease (ESRD) provided under Title XVIII of the Social Security Act. |
| Medicare Part A: |
Compulsory hospitalization insurance that provides specified in-hospital and related benefits. All workers covered by Social Security finance its operation through a portion of their FICA tax. |
| Medicare Part B: |
Voluntary program designed to provide supplementary medical insurance to cover physician services, medical services and supplies not covered under Medicare Part A. |
| Medicare Supplement Policy: |
Health insurance that provides coverage to fill in the gaps in Medicare coverage. |
| Member Number: |
Company number with a 4-digit suffix assigned to each subscriber in the company. |
| - N - |
| - O - |
| Open Enrollment Period: |
A period during which subscribers in a health benefit program have an opportunity to select an alternate health plan being offered to them, usually without evidence of insurability or waiting periods. |
| - P - |
| Participating Provider: |
A provider who has contracted with the health plan to provide medical services to covered persons. The provider may be a hospital, pharmacy, other facility or a physician who has contractually accepted the terms and conditions as set forth by the health plan. |
| Point of Service (POS): |
A health plan whose members can choose their services where they need them, either in the HMO or from a provider outside of the HMO at some cost to the member. |
| Policy: |
In insurance, the written instrument in which a contract of insurance is set forth. |
| Pre-admission Certification: |
A review of the need for inpatient hospital care prior to the actual admission. Established review criteria are used to determine the appropriateness of inpatient care. |
| Pre-existing Condition: |
Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage under the master group contract. |
| Preferred Provider Organization (PPO): |
A program in which contracts are established with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides significantly better benefits (fewer copayments) for services received from preferred providers, thus encouraging members to use these providers. Members are generally allowed benefits for non-participating providers' services, usually on an indemnity basis with significant copayments. A PPO arrangement can be insured or self-funded. Providers may be, but are not necessarily, paid on a discounted fee-for-service basis. |
| Premium: |
The amount paid for providing coverage under a contract. Premiums are typically set in coverage classifications such as: individual, two-party and family; employee and dependent unit; employee only, employee and spouse, employee and child, and employee, spouse and child. |
| Probationary Period: |
A specified number of days established by an employer before an employee is eligible for group insurance coverage. |
| - Q - |
| - R - |
| Reasonable and Customary: |
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. |
| Reinstatement: |
Restoring coverage of a lapsed policy by producing satisfactory evidence of insurability and paying any past-due premiums required. |
| - S - |
| Service Fee: |
Fee paid to a broker for a block of business. |
| Sole Proprietorship: |
A business organization whereby one individual owns and controls the entire company. |
| Subscriber: |
The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan. |
| Summary of Benefits: |
Informational material about a specific insurance plan or policy that describes the policy's features and benefits.
|
| - T - |
| Transaction: |
An enrollment activity reported to the carrier that results in the addition, adjustment or termination of a subscriber's coverage. |
| - U - |
| Underwriting: |
Process through which an insurer determines whether, and on what basis, an insurance application will be accepted. |
| Utilization Review (UR): |
A formal review of patient utilization or of the appropriateness of health care services, on a prospective, concurrent or retrospective basis. |
| - V - |
| - W - |
| - X - |
| - Y - |
| - Z - |
