accidental death and dismemberment (ad&d;) rider
A supplement to many life insurance policies that provides an additional cash benefit to the insured or his/her beneficiaries if an accident causes either the death of the insured or causes the insured to lose any two limbs or the sight in both eyes.
annual out-of-pocket maximum
A dollar amount set by the plan which puts a cap on the amount of money the insured must pay out of his or her own pocket for covered expenses over the course of a calendar year.
The person or business that applies for an insurance policy.
BbeneficiaryThe person or party the owner of a life insurance policy names to receive the policy benefit in the event of the insured's death.
Prescription medications that are manufactured by the developer of the medication in question.
A sales agent who is under contract to and sells the insurance products of more than one insurance company.
The amount of health care expenses that the insured person must pay before insurance payments for covered eligible expenses.
A utilization management technique that addresses the medical necessity of care as well as alternative treatments or solutions, especially when the patient is likely to require very expensive treatment.
certificate of insurance
A document that describes the type and length of coverage provided by a group insurance policy that is given to each insured by the group policyholder.
Not all plans cover chiropractors -- practitioners who manipulate the spine and other structures within the body to relieve pain and tension resulting from posture, stress or strain. Some plans offer chiropractic care as an optional benefit that you or your employees may choose to add at an additional cost.
A request for payment under the terms of an insurance policy.
An insurance company employee/representative who is responsible for carrying out the claim examination process. Also known as claim approver, claim analyst, or claim specialist.
cobra (consolidated omnibus budget reconciliation act)
COBRA requires organizations with twenty or more employees to offer the continuation of group health benefits (Medical, Dental, Vision, and Medical Reimbursement Account) to employees (and covered dependents) upon experiencing a "Qualifying Event."
Employers are required to provide initial COBRA notification to covered employees and dependents. A letter detailing an individual's rights upon experiencing a "qualifying event" and an explanation of the conversion privilege. The legislation defines the following six situations as "Qualifying Events" that require COBRA continuation:
- Termination of Employment
- Reduction of Work Hours
- Employee's Death
- Employee's Divorce (or legal separation in some states)
- Medicare Entitlement
- Change in "Dependent" Status
A specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the policy's deductible has been met.
The amount of money, usually a percentage of the premiums, that is paid to an insurance agent for selling an insurance policy.
comprehensive major medical policy
A health insurance policy that covers both major medical expenses (i.e., hospitalization and surgeries) and basic medical expense coverages.
The fee you pay for certain medical services or for each prescription. For example, you may pay $20 for an office visit or $10 to fill a prescription and the health plan covers the balance of the charges. (1) A fee that many insurance plans require an insured to pay for certain medical services (such as a physician's office visit). (2) An amount that the insured must pay toward the cost of each prescription under a prescription drug plan.
A flat amount of covered medical expenses that an insured must incur before the insurer will make any benefit payments under a medical expense policy.
dental -- benefits
Some health plans offer dental care as an optional benefit or rider that you or your employees may decide to add at an additional cost.
A person for whom the insured has some legal obligation to. For most plans, it is the insured's spouse and/or children. Some plans also allow non-traditional spousal relationships (significant other, life-partner, etc.) to be considered a dependent with some additional certifying paperwork.
Domestic partners are commonly defined as "two adults who share an emotional, physical and financial relationship similar to that of a married couple but who either choose not to marry or cannot legally marry. They share a mutual obligation of support for the basic necessities of life." Additionally, some carriers may require that domestic partners own property together to qualify.
Dual choice allows an employer to offer his employees not one, but two health plans. Instead of picking the least expensive plan for all employees, Dual Choice lets employees choose the type of plan that best meets their needs or budgets. Usually, this is a choice of an HMO and PPO, or HMO and POS. The employer will typically pay a portion of the premium in these plans, and the employee will pay the balance. Here are a few approaches:
- An employer may pay for the lower cost plan and employees may buy up to the more expensive plan.
- An employer may pay a set amount per month for every employee.
- An employer may charge all employees the same amount and pay the balance, regardless of the plan each employee selects.
The specified date of when the health insurance policy is to begin.
Most plans cover emergency care in a hospital emergency room if it is an extremely urgent medical emergency, even if the hospital you are taken to is not in the plan's network. It is possible, however, that after your condition has been stabilized, you would be transferred to a participating plan hospital.
A visit to a hospital for treatment of an accidental injury or for emergency medical care. To qualify as an emergency, the symptoms must be sudden, severe and require immediate medical attention. Some states judge emergencies by the "prudent layperson" law, meaning that the health plan must cover a trip to the emergency room "if a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed." Keep in mind that some plans won't cover a trip to the emergency room if the symptoms appeared more than 24 hours earlier.
The amount of premium the employer requires the employee to pay for his or her health insurance.
enrollment or eligibility period
The time during which a new group member may first enroll for group insurance coverage.
exclusions and limitations
Conditions, situations and services not covered by the health plan.
An Individual/Family Medical Plan is renewable for multiple years and provides continuous claims coverage. Most healthcare companies offer comprehensive major medical plans that cover both major medical expenses (e.g., hospitalization and surgeries) and routine medical expenses (e.g., office visits and annual exams). In addition, they typically offer a variety of plan types to choose from, such as PPOs, HMOs and POSs.
fee schedule payment structure
A fee structure used by insurers under which the insurance company places caps or limits on the dollar amounts that it will reimburse providers covered medical procedures and services, both in and out-of-network if applicable. Also known as a limited fee schedule.
Also called an indemnity plan. A health insurance plan that allows the insured to use any medical provider that he or she chooses. As such, there are no networks to utilize.
flex-term medical coverage
See "short-term medical coverage."
Formulary drugs generally have a lower copay. A formulary drug is one that has been thoroughly reviewed by a team of expert pharmacists and physicians; these drugs have been identified as safe, effective and beneficial to members for treating medical conditions. When deciding between drugs which are equally safe and effective, the formulary team also considers the relative costs of medications. These savings are then passed on to you through lower premiums.
fully insured plan
A group insurance plan for which an insurance company bears the responsibility of making all claim payments.
fully self-insured plan
A group insurance plan under which the employer takes complete responsibility for all claim payments and related expenses rather than purchasing coverage from an insurance company.
A term used to describe the primary care physician's role in a managed care plan; this role is to authorize all services delivered to the insured by other physicians or health care providers. Thus, whenever you wish to see a physician other than your primary care physician, you must first obtain his or her permission (via a referral).
When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name, but once its patent expires, other companies can sell the same drug under its chemical, or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the Food and Drug Administration requires generic drug manufacturers to show that a generic drug "delivers the same amount of active ingredient in the same time frame as the original product."
group term life
A life-insurance plan that provides employees with additional coverage at economical group rates.
guaranteed renewable policy
A health insurance policy that the insurer is required to renew -- as long as premiums are paid -- at least until the insured attains the age limit specified in the policy, or the policy is cancelled by the insured. The insurer may increase the premium rate for any class of guaranteed renewable policies.
health care provider
A doctor, hospital, laboratory, nurse or anyone else who delivers medical or health-related care.
A type of insurance that provides protection against the risk of financial loss resulting from the insured person's sickness, accidental injury or disability.
health insurance portability and accountability act of 1996 (hipaa)
Under this federal law (known as HIPAA), group health plans cannot deny coverage based soley on an individual's health status. This law also gives employees who change or lose their jobs better access to health coverage, guarantees renewability and availability to certain employees and limits exclusions for pre-existing conditions. For example, under this law, group health plans must credit any employee the amount of time that they spent on any health plan prior to the new plan, which is known as "prior credible coverage." A pre-existing condition will be covered without a waiting period when an employee joins a new group plan if the employee has been insured for the previous 12 months with credible health insurance, with no lapse in coverage of 63 days or more. This means that if an employee has been insured for 12 months or more, the employee will be able to go from one job to another and his or her pre-existing coverage will remain intact -- without additional waiting periods. However, if an employee has a pre-existing condition and was not covered previously for 12 months before joining a new plan, the longest the employee will have to wait for their pre-existing coverage to be covered is 12 months.
hmo (health maintenance organization)
A health care financing and delivery system that provides comprehensive health care for subscribing members in a particular geographic area using managed care techniques. Most HMOs require that you only utilize physicians within their network, often going so far as to require you to choose a primary care physician who directs most courses of your treatment.
home health care
Skilled medical care and other health care services that you receive in your home for the treatment of an illness or injury. Some insurance plans don't provide this kind of coverage, or provide it only for a limited amount of time.
hsa (health savings account)
An HSA is a high deductible medical plan that includes a tax deferred savings account. The money from the savings account can be used to:
- help meet the deductible
- help pay early hospitalization/medical expenses
- used towards personal retirement savings
Also called a fee-for-service plan. A health insurance plan that allows the insured to use any medical provider that he or she chooses. As such, there are no networks to utilize.
An Individual Medical Plan is renewable for multiple years and provides continuous claims coverage. Most healthcare companies offer comprehensive major medical plans that cover both major medical expenses (e.g., hospitalization and surgeries) and routine medical expenses (e.g., office visits and annual exams). In addition, they typically offer a variety of plan types to choose from, such as PPOs, HMOs and POSs.
individual practice association (ipa)
A type of open-panel HMO that contracts with an association of physicians who agree to provide services for HMO members.
Medical procedures which require the patient to spend at least one night at the hospital. Most plans limit the amount of time an inpatient may stay at the hospital following surgery.
A person authorized by an insurance company to represent the company in its dealings with applicants for insurance.
The person whose life or health is insured under an insurance policy. Also referred to as a "member."
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This option is offered by some plans to provide a set amount of life insurance for the insured's spouse, domestic partner or children.
The maximum amount of money a plan will pay towards healthcare services over the course of the insured's lifetime.
major medical insurance plan
A type of traditional medical expense coverage that provides substantial benefits for hospital surgical expenses and physicians' fees.
A method of integrating the financing and delivery of health care within a system that seeks to manage the cost, accessibility and quality of care.
Many individual plans and some small-group plans for groups of fewer than 15 employees don't cover the costs associated with pregnancy and birth. However, federal law requires that group plans cover maternity if a group has 15 employees or more.
The person whose life or health is insured under an insurance policy. Also referred to as the "insured."
mental health - inpatient
Inpatient mental health care is generally reserved for severe mental health problems, such a schizophrenia and severe depression. State laws vary widely on the degree to which insurance companies must cover mental illness. Most plans do provide some coverage, though there may be limitations such as the severity or nature of the illness and the duration of care.
mental health - outpatient
Outpatient mental health benefits are generally divided into two categories, severe and non-severe health care. State laws vary widely on the degree to which insurance companies must cover mental illness. Most plans do provide some coverage, though there may be limitations such as the severity or nature of the illness and the duration of care.
msa -- benefits
The newest choice in health insurance for the self-employed, Medical Savings Accounts (MSAs) allow you to build up a tax-free savings account to pay for routine medical expenses.
You build the account with tax-free dollars, and they remain tax-free while your MSA is active. Your MSA is used in conjunction with a high-deductible insurance policy.
With the high-deductible insurance plan, the cost of an MSA can be kept competitively low. Tax-free dollars and an affordable price save you money.
A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.
Non-formulary drugs often require a higher copayment. Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan's formulary list.
non-severe mental health
Non-severe mental health problems are generally psychologically-based, such as phobias, manias and mild-to-moderate depression. In most cases, these problems can be treated without a stay at a treatment facility.
Health care services received outside the HMO, POS or PPO network.
Any medical care costs not covered by insurance, which must be paid by the insured.
Surgery that does not involve an overnight stay in a hospital.
Not all plans cover physical therapy -- a program of special exercises that can help an injury heal without restricting movement or limiting function.
physicians office visit
Any time you visit a doctor at his or her office for medical care.
An HMO plan that also incorporates an indemnity plan option allowing members to obtain medical care from providers outside of the HMO network at a reduced benefit and at greater out-of-pocket expense.
A written document that contains the terms of the contractual agreement between an insurance company and the owner of policy.
The period of time that the policy is to remain in force.
The person or business that owns an insurance policy.
Group insurance coverage that can be continued by an insured employee who leaves the covered group.
pos (point-of-service plan)
An HMO plan that also incorporates an indemnity plan option. You can decide whether to go to a network provider for lower out of pocket costs, or go to an out-of-network provider and higher out of pocket costs.
ppo (preferred provider organization)
An organization where providers are under contract to an insurance company or health plan to provide care at a discounted or negotiated rate. Typically, you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. Most PPOs will also allow you to seek care outside of the PPO network; however, the benefits are usually reduced and the insured has a greater out-of-pocket expense.
A component of utilization review under which the utilization review organization determines whether an insured's proposed non-emergency hospital stay or some other type of care is most appropriate and what the length of an approved hospital stay may be.
(1)According to most individual health insurance policies, an injury that occurred or a sickness that first appeared or manifested itself before the policy was issued and that was not disclosed on the application for insurance. (2) According to most group health insurance policies, a condition for which an individual received medical care during the three months immediately prior to the effective date of his coverage.
pre-existing conditions provision
A health insurance policy provision stating that benefits will not be paid for any illness and/or condition that existed prior to one becoming an insured under the particular health plan in question until the insured has been covered under the policy for a specified period.
A specified amount of money that the insurer receives in exchange for its promise to provide health insurance to an individual or a group.
prescription drug coverage (rx)
A type of specified expense coverage that provides benefits for the purchase of drugs and medicines prescribed by a physician and not available over-the-counter. Often a plan will provide a prescription drug card that allows the insured to obtain medications by simply paying a copay at a participating pharmacy.
primary care physician (pcp)
A general or family practitioner who serves as the insured's personal physician and first contact with a managed care system. The PCP will usually direct the course of your treatment and/or refer you to other doctors and/or specialists in the network.
The length of time that a new group member must wait before becoming eligible to enroll in a group insurance plan.
QquoteThe preliminary amount of premium the insured and/or group will pay per month before underwriting factors are considered.
The specified date of when the health insurance coverage will renew for another period, typically one year.
routine annual exam
A yearly medical "checkup," during which your doctor will perform simple medical care such as checking your height, weight, vision and blood pressure, as well as screening for problems like colon cancer, cervical cancer, prostate cancer and high cholesterol.
rx drug: formulary/non-formulary
Some plans divide all drugs into two categories: formulary or non-formulary. If you have drug coverage, your prescription (RX) copayment may be different for formulary and non-formulary drugs.
severe mental health
As defined by the American Psychiatric Association in their Diagnostic and Statistical Manual (DSM), severe mental illness includes the following disorders: schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa and bulimia nervosa. Such problems generally require at least occasional inpatient care.
This type of coverage pays a percentage of your salary if you become temporarily disabled, meaning that you are not able to work for a short period of time due to sickness or injury (excluding on-the-job injuries, which are covered by workers compensation). The per-week amount is usually 50, 60 or 66 2/3 percent of your weekly salary, and lasts for a period of time specified by the plan.
short-term medical coverage
Similar to flex-term medical coverage. Short-term medical coverage is a major medical plan designed to protect you in the event of an illness or injury during "gaps" in your traditional medical coverage -- when you are between jobs or plans, a recent graduate, on strike, etc. Short-term plans are not meant to cover routine exams and preventive care; if you are looking for a choice of plan types and the ability to renew your plan beyond one year, a traditional medical plan, while typically more expensive, may be a better fit for your health insurance needs.
A level of care for patients who need intensive, 24-hour nursing supervision. This can take place in the home or in skilled nursing facilities, which offer services such as rehabilitation and specialized nutrition.
A health insurance plan that is specifically designed for employers with a number of employees under a specified amount.
standard industrial classification (sic)
The Standard Industrial Classification (SIC) system is a series of number codes that attempts to classify all business establishments by the types of products or services they make available. Establishments engaged in the same activity, whatever their size or type of ownership, are assigned the same SIC code. These definitions are important for standardization. Insurance companies use SIC codes to determine specific rates for various industries. HealthInsurance.com uses these codes to ensure that you receive the best possible rate for your occupation.
standard risk rate
The risk category that is composed of proposed insureds who have a likelihood of loss that is not significantly greater than average.
A major medical policy provision under which the insurer will pay 100 percent of the insured's eligible medical expenses after the insured has incurred a specified amount of out-of-pocket expenses in deductible and coinsurance payments.
This kind of coverage provides extra financial security for you and your family in the event of accidental death or dismemberment.
term life insurance
A type of life insurance that provides a death benefit if the insured dies during a specific period.
Insurance company employees who are responsible for identifying and classifying the degree of risk represented by a proposed insured.
The process of identifying and classifying the degree of risk represented by a proposed insured.
Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached the level of extreme emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.
usual, customary and reasonable fee
The maximum dollar amount of a covered expense that is considered eligible for reimbursement under a major medical policy.
vision care coverage
A type of specified expense coverage that provides benefits for expenses the insured incurs in obtaining eye examinations and corrective lenses.
The goals of well-baby care are:
- to immunize;
- to provide parents with reassurance and counseling on safety, nutrition and behavioral problems; and
- to identify and treat physical and developmental problems.
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So much information, so little time
HealthInsurance.com understands busy schedules. With that in mind, here's a no-frills, easy-accessguide to health insurance.
Understanding Health Insurance
No single plan will cover all costs associated with medical care, but some cover more than others. Want to unlock the differences between plans? Here's your key ...
Types of Coverage:
Fee-for-Service (or Indemnity) Plans
With this traditional plan, you can make an appointment with almost any medical provider. After your visit, you or your provider sends your claim to the insurance company. If you have met your deductible for the year, then the Fee-for-Service plan will pay a percentage of the bill – usually 80%. You pay for the other 20%, known as coinsurance. Few purchase this traditional type of plan. Why? Because it's expensive.
This term refers to types of health insurance plans that provide health care services at a lower cost. The key to these lower costs? Members of managed care plans must adhere to certain rules designed to lower the cost of medical care.
Types of Managed Care:
Health Maintenance Organizations (or HMOs)
With an HMO, you receive a range of health benefits for a set fee. Generally, there are no deductibles – but most plans require a small copay per office visit (around $10-25). You must choose a primary care physician from the plan’s list. This doctor becomes your “gatekeeper” for all your medical needs. This is the doctor you call or see when you are sick, and he or she will refer you to a specialist or other providers within the HMO network. With most HMOs you will not receive benefits if you go out-of-network, except for emergency care.
Types of HMOs:
- Staff Model HMO
A form of HMO in which doctors are employees of the HMO and you see them at a central medical facility.
- Individual Practice Associations (IPAs)
Here, an HMO contracts with outside physician groups or individual doctors who have private practices. This means the HMO network will include doctors in various locations rather than only at a central facility.More Types of Managed Care:
Preferred Provider Organization (PPO)
This isn't an HMO, but it is another type of managed care. In this system, you may seek treatment from an approved network of providers, or may see other providers outside the network. Usually, you will pay small copay and satisfy a deductible before benefits are paid. Then you’ll pay a set coinsurance amount. It’s less expensive to visit one of the providers in the plan’s list. You can go outside the plan’s list, but your share of the bill will be higher.
Point of Service (POS)
A hybrid of the HMO and PPO is known as a POS plan. Like a standard HMO, your primary care doctors make referrals to other providers within the plan. But if you want to go to a physician outside the network without consulting your primary care doctor, the POS plan will pay a predetermined amount of the bill and your share of the bill will be higher than it would if you stay in-network. These plans usually cost more in monthly premiums than straight HMOs, but they give you the flexibility to call any doctor – within the plan or not.
If you have a choice from more than one plan, compare how each plan handles the following:
- Pre-existing conditions
- Limitations on devices, drugs, and access to specialists.
Health Savings Accounts
Health Savings Accounts (HSAs) are a relatively new way for Americans to pay for their healthcare. Like an IRA, the money deposited into an HSA is completely tax-deductible. These accounts, however, can be accessed whenever individuals need them to pay for qualified healthcare expenses. In the meantime, their money earns tax-free interest for future medical costs.
For more information regarding HSA's, click here.
Wondering about some of the terms used in health insurance?
Here are some common terms and definitions.
A fixed dollar amount you pay at the time services are rendered. Typical copays are for office visits, prescriptions, or hospitalizations.
A specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the deductible has been met.
The portion of your health care that you pay before insurance starts covering it. Typically, the higher the deductible, the lower the premiums.
An illness, disease or condition an individual has at the time of enrollment in a health care plan.
The monthly or quarterly payments paid for health insurance.
This plan pays hospital and medical expenses above a certain (usually high) deductible. The maximum lifetime limit may be high enough to cover the cost of a catastrophic illness.
Long-term care policies:
These cover medical care, nursing care and certain in-home care if you ever become unable to care for yourself dueto an extended illness or disability.
Disability income insurance:
This plan will provide you with an income if you become unable to work due to an injury or illness. Benefits areusually 60% of your income at the time of disability.
When insuring your child(ren) only, each child must be entered and submitted separately.
For one child, enter the information on that child in the "Please enter your family information" section.
1 year old
At this time we cannot quote children under 1 year of age separately online. Please call us for an offline quote or more information.
If you want to insure more than one child, each child must be entered and submitted separately.
For each child, enter the information on that child in the "Please enter your family information" section
18 + up
If you want to insure more than one child, each child must be entered and submitted separately.
For each child, enter the information on that child in the "Please enter your family information" section.
In many cases, when your children go off to college, they are in a different state, or even a different country, which can complicate your health insurance. If your student is traveling abroad you may be interested in information on international & travel medical. Close this window, return to the home page and click on "international & travel medical".