Glossary of Health Insurance Terms

Benefit: The dollar amount your insurance carrier will pay when you file a claim for a covered loss.

Benefit Period: The interval during which you will be eligible for benefits. Generally, your benefit period will begin with the first medical service you received for a specific illness and end after you have not been treated for that condition for 60 days.

Catastrophic Insurance: In health insurance, usually refers to a policy with a high deductible.

Carrier: The insurance company from whom you receive your health plan.

Certificate of Insurance: This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier. It spells out precisely what will be covered, what won't, and the dollar maximums.

Children's Health Insurance Program (CHIP). A program, established by the Balanced Budget Act, designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs. https://www.coaccess.com/public/cHPPlus.jsp

Claim: This refers to any request to your insurance company for benefits.

COBRA: Short for Consolidated Omnibus Budget Reconciliation Act. A federal law under which group health plans sponsored by employers with 20 or more employees must offer continuation of coverage to employees and their dependents who leave their jobs. The employee must pay the entire premium. Coverage can be extended up to 18 months. Surviving dependents can receive longer coverage. http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.html

Co-insurance: The percentage of each claim above the deductible paid by the policyholder. For a 20 percent health insurance coinsurance clause, the policyholder pays for the deductible plus 20 percent of his covered losses. After paying 80 percent of losses up to a specified ceiling, the insurer starts paying 100 percent of losses.

Colorado Division of Insurance: A Colorado State agency that regulates the insurance industry and assist consumers and other stakeholders with insurance issues that are important to them. Coloradans needing assistance with insurance issues may call 303 894-7490 in the Denver-Metro area and 1 800 930-3745 from other parts of the state. http://www.dora.state.co.us/insurance/consumer/healthmain.htm

Co-payment: A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered, i.e. $40.00 per office visit, $75 per emergency room visit or $10.00 per generic prescription.

CoverColorado: CoverColorado is a non-profit entity created by the Colorado Legislature to provide medical insurance for eligible Colorado residents who, because of a pre-existing medical condition, are unable to get coverage from private insurers. www.Covercolorado.org

Covered Expenses: The various medical procedures for which your insurer has agreed to provide you coverage.

Deductible: A flat amount an insured must pay before the insurer will make any benefit payments. Usually, the higher the deductible, the lower the premium.

Effective Date: This refers to the date on which your insurance coverage will actually begin to cover you.

Exclusion: A provision in an insurance policy that eliminates coverage for certain risks, people or health conditions.

Fee-for-Service: The fee determined by an insurer to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum, or capped fee.

Group of one: Under federal law, employer group plans are defined as those sponsored by firms with two (2) or more employees. In Colorado, however, group health insurance has been defined more broadly to include "groups of one," that is, self-employed individuals with no other employees. Often of interest to self-employed individuals with pre-existing medical conditions.

Health Insurance Portability and Accountability Act (HIPAA): A federal act that protects people who change jobs, are self-employed, or who have pre-existing medical conditions. HIPAA standardizes an approach to the continuation of healthcare benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.

HMO: This is acronym stands for Health Maintenance Organization. HMO’s are prepaid, health benefit programs in which you’ll pay monthly premiums in return for managed coverage for your checkups, hospital stays, doctors' visits, surgery, emergency care, preventive care, lab tests, and X-rays. If you join an HMO, you will have to select what’s called a “primary-care physician” who will be responsible for coordinating your healthcare and making any referrals to specialists that you require. You’ll also have to use doctors, hospitals and clinics who are members of your HMO plan's network.

(HSA) Health Savings Account: Operating similarly to IRA’s, HAS’s are tax-advantaged savings accounts for health care services.  A person must enroll in a qualified High-Deductible Health Plan (HDHP) before they can establish an HSA.

Individual Market: A market segment composed of customers who are not members of a group and not eligible for Medicare or Medicaid who are covered under an individual contract for health coverage.

In-network: Healthcare facilities or providers who are members of your health plan.

Lifetime Limit: This refers to the cap (or maximum level) on benefits available through a policy.

LOS: This is an acronym for the term length of stay. It's used by insurance carriers, case managers, and other healthcare professionals to describe the length of time any individual spends in a hospital or an in-patient care facility.

Maximum Out-of-Pocket Expenses: The most you will have to pay during one year in the form of deductibles and coinsurance fees.

Managed Care: This term refers to an increasingly broad assortment of health plans that manage healthcare costs and usage. There are three major types of managed health plans: HMOs (Health Maintenance POS (Point-Of-Service plans). Organizations), PPO’s (Preferred Provider Organizations) and

Medicaid: A federal/state public assistance program created in 1965 and administered by the states for people whose income and resources are insufficient to pay for health care.
Medicare: Federal program for people 65 or older that pays part of the costs associated with hospitalization, surgery, doctors’ bills, home health care, and skilled-nursing care.

Network: This refers to the groups of doctors, hospitals and other medical professionals who have been contracted to provide discounted healthcare services to your insurance carrier’s customers.

Out-of-Network: This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO, POS, or PPO). Depending on your plans guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.

Point-Of-Service (POS) Product. A healthcare option that allows members to choose at the time medical services are needed whether they will go to a provider within the plan's network or seek medical care outside the network.

Pre-existing Conditions: This refers to any healthcare issues you had prior to your insurance plans effective date. Many policies will refuse to cover pre-existing conditions, while others do so with a rate-up

Preferred Provider Organization (PPO). A healthcare benefit arrangement designed to supply services at a discounted cost by providing incentives for members to use designated healthcare providers (who contract with the PPO at a discount), but which also provides coverage for services rendered by healthcare providers who are not part of the PPO network.

Preventative Care: Health services that focus solely on preventative care measures such as physical exams, immunizations, diagnostic tests and mammograms.

Premium: The price of an insurance policy usually changed annually on the anniversary of the effective date.

Primary Care Physician: Most HMOs and POS plans will require you to select one family physician, pediatrician or internist to monitor your health, treat most of your health problems, and refer you to specialists when necessary.

Provider: This term refers to any individual (nurse, physician, or specialist) or institution (clinic, hospital, or laboratory) that provides you with care.

Rate-Up: A rate-up is the extent to which premiums are increased, usually in consideration of a pre-existing condition.

Rider: An attachment to an insurance policy that alters the policy’s coverage or terms.

Short Term Health Insurance: This type of healthcare plan is purchased to provide you with benefits during coverage gaps between jobs, after a move, or while you're traveling overseas.

Small Business Health Insurance: This is a type of healthcare coverage that is available to businesses employing between two and fifty employees. It offers discounted premiums to employees and tax advantages to small business owners; also in most cases, the coverage cannot be denied.

Travel Health Insurance: Insurance to cover health care and problems associated with traveling, that may include trip cancellation due to illness, lost luggage and other incidents. https://www.imglobal.com/travelinsurance/index.cfm?imgac=186820