Glossary of Terms


Beneficiary: A person who receives benefits of any insurance plan or policy.

 

Certificate holder: An employee or other insured named under a group health insurance policy.

 

Claim: A request for payment for services.

 

COBRA: Federal law requiring that workers who end employment for specified reasons have the option of purchasing group insurance through the employer for a limited period of coverage (usually 18 months, but in some cases, 29 months or 36 months).

 

Coordination of Benefits (COB): Provisions and procedures used by insurers to avoid duplicate payments when a person is covered by more than one policy.

 

Co-payment (co-insurance): A specified dollar amount or percentage of covered expenses that an insurance policy or Medicare requires a beneficiary to pay toward eligible medical bills.

 

Covered services: Services for which an insurance policy will pay.

 

Deductible: A specified dollar amount of medical expenses that the beneficiary must pay before an insurance policy will pay.

 

Exclusion: A procedure or condition that an insurance policy does not cover.

 

Experimental: Medical treatment that is not generally accepted within the medical profession. Insurance policies often do not cover these procedures.

 

Explanation of Benefits (EOB): A statement from an insurance company showing which payments have been made on a claim.

 

Fee-For-Service: Traditional insurance that does not place restrictions on which doctors you can use. The insurer pays for the expense incurred.

 

Group insurance: A contract between an insurer and an employer or association.

 

Health Insurance Portability & Accountability Act (HIPAA): Federal law that guarantees health care plan eligibility for people who change jobs if the new employer offers group insurance.

 

Health Insuring Corporation (HIC): A term for managed care insurers in Ohio. HICs include all Ohio HMOs and other companies that offer prepaid managed care.

 

Individual health insurance: A contract between an insurance company and an insured person.

 

Inpatient: A person who has been admitted to a hospital or other health care facility to receive diagnosis, treatment or other health services.

 

Insured: An individual or organization protected by an insurance policy.

 

Long-term care (LTC): The medical and social care given to one who has a severe chronic impairment over a long period of time.

 

Managed care: A term traditionally confused with the term HMO. A general term used to describe a system that focuses on improving quality and controlling prices. Managed Care includes HMOs, PPOs and POS plans.

 

Medically necessary: Treatments or services an insurance policy will pay for as defined in the contract.

 

Open enrollment: A period of time when new subscribers may enroll in a health insurance plan regardless of their health.

 

Outpatient: A patient who receives care at a hospital or other health care facility without being admitted to the facility.  Outpatient care also refers to care given in other locations such as outpatient clinics.

 

Pre-certification (also called Utilization Review): Requires an insured to obtain the insurance company’s approval before a medical service is provided.  If the insured fails to follow the pre-certification procedures, the company may reduce or deny claim payment.  Getting pre-certification does not guarantee claim payment.

 

Premium: Money paid in advance for insurance coverage.

 

Primary payer: Health insurance policy that pays first when a person is covered by more than one insurance plan.

 

Provider: A person or organization that provides medical services, such as a doctor, hospital, x-ray company, home health agency, pharmacy, etc.

 

Secondary payer: Applies only when the insured has more than one health insurance plan. The secondary payer is the plan whose payments cannot be made until another plan (the primary payer) has processed the claim. (Also see Coordination of Benefits)

 

Self-insured plan: An organization (usually an employer) that pays health care costs out of the organization’s own pocket.