A

• Accelerated Benefits — Life insurance riders allowing the policy’s death benefits to offset expenses incurred in a convalescent or nursing home facility
• Access — Availability of medical care. Determined by availability of transportation, location, type of medical services in the area, etc.
• Accident Insurance — Insurance against loss by accidental bodily injury to the insured.
• Accidental Death and Dismemberment (AD&D) — Policy or provision in Disability Income policy that pays a specified amount or a multiple of the weekly disability benefit should the insured die, lose his sight, or lose two limbs as the result of an accident. Lesser amount is payable for the loss of one eye, arm, leg, hand, or foot.
• Accidental Death Benefit — Extra benefit that, in general, equals the face of the contract or principal sum, payable in addition to other benefits in the event of death as the result of an accident.
• Actively-at-work — Depending upon the policy, if an employee is not actively at work on the day the policy goes into effect, coverage does not begin until the employee returns to work.
• Activities of Daily Living (ADLs) — Activities performed by individuals without assistance in the course of day to day living that include mobility, dressing, personal hygiene and eating.
• Activities of Daily Living Standards — Standards assessing the ability of an individual to live independently, measuring the ability to perform unaided such activities as eating, bathing, toiletry, dressing, and walking. Standards are often discussed as a measurement or definition of eligibility for long-term care.
• Actual Charge — Actual amount charged by a physician for medical services.
• Acute Care — Medically necessary, skilled care provided by nursing and medical personnel to restore a person to good health.
• Additional Monthly Benefit — Riders added to disability income policies to providing additional benefits for the first year of a claim while the insured is waiting for commencement of Social Security benefits.
• Admits — Number of admissions to a hospital (includes outpatient and inpatient facilities).
• Adult Day Care — Group program for functionally impaired adults. Meets some health, social and functional needs in a setting other than adult’s home.
• Aftercare — Patient services, customized to the individual, required after hospitalization or rehabilitation.
• Age Change — For insurance purposes, date that a person’s age changes. In majority of Life Insurance contracts, defined as the date midway between the insured’s natural birth dates. For Health Insurance purposes, the age of the previous birth date is frequently used for rate determinations. Based upon the rating structure of the particular insurer, on the date of age change, a person’s age may change to that of the last birth date, the nearer birth date, or the next birth date.
• Age/Sex Factor — A measurement is used in underwriting; comparing the age and sex risk of medical costs of one group in relation to another.
• Ancillary Service — Services other than hospital room and board, nursing, and physician services. (e.g. lab and x-ray work)

B

• Basic Hospital Expense Insurance — Benefits provided by hospital coverage for room and board and miscellaneous hospital expenses for specified number of days during hospital confinement.
• Benefit Levels — Maximum amount a person is entitled to receive for particular services as described in the contract with insurer or health plan.
• Benefit Package — Description of services offered by insurer or health plan to those covered under the terms of health insurance contract.
• Benefit Period — Period during which Medicare beneficiary is eligible for Part A benefits. Benefit period is 90 days, beginning the day of patient’s admission to hospital and ending when individual has not been hospitalized for a period of 60 consecutive days.
• Billed Claims — Amounts submitted by health care provider for services provided to a covered individual.
• Birthday Rule — A method determining which parent’s medical coverage is primary for dependent children: parent whose birthday falls earliest in the year is usually considered to have the primary plan.
• Blue Cross — Nonprofit hospital expense prepayment plans primarily designed to provide benefits for hospitalization coverage.
• Blue Plan — Generic designation for those licensed companies, authorized to use the designation Blue Cross or Blue Shield and the corresponding insignia.
• Blue Shield — Blue Shield plans are prepayment plans offered by voluntary nonprofit organizations that cover medical and surgical expenses.
• Board Certified — Physician or other professional who has passed an examination certifying him as a specialist in a particular medical area.
• Board Eligible — Professional person or physician eligible to take a specialty examination.
• Business Overhead Expense — Disability income policy indemnifying the business for specified overhead expenses incurred should the business owner become totally disabled.

C

• COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986) — Legislation providing a continuation of group health care benefits under group plans for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may continue up to 36 months in other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.
• Calendar Year — January 1 through December 31 of the same year. Under major medical plans, many deductible amount provisions are on based a calendar year. Benefits under basic hospital surgical and medical plans are based on an amount per calendar year.
• Capitation (CAP) — A rate paid to a health care provider, usually monthly. The provider agrees to deliver health services as agreed upon to covered persons.
• Carrier — Commercial insurance company providing group health care benefits.
• Carry Over Provision — For major medical policies, an insured that has submitted no claims during the year can apply any medical expenses incurred in the last three months of the year toward the next calendar year’s deductible.
• Case Management — Assessment of a person’s long term care needs and followed by appropriate recommendations for care, monitoring and follow-up as applies to extent and quality of services to be provided.
• Case Manager — Person, usually experienced professional, who coordinates services necessary for case management approach.
• Certificate of Need (CON) — Government issued certification that the proposed facility meets the needs of those for whom it is intended. The need may involve constructing a new health facility, offering new or different health services, or acquiring new medical equipment.
• Chemical Dependency Services — Services required for treatment and diagnosis of chemical dependency, alcoholism, and drug dependency.
• Closed Access — Situation in which covered insureds must select a sole primary care physician. This physician is the only one able to refer the patient to other health care providers within the plan. Also called Closed Panel or Gatekeeper.
• Cognitive Impairment — Deficiency in ability to think, perceive, reason or remember. Results in loss of ability to attend to one’s daily living needs.
• Coinsurance Clause — Provision stating that insured and insurer will share all losses covered by the policy in a previously agreed upon proportion, i.e., 80-20 means the insurer would pay 80% and the insured would pay 20% of all losses.
• Composite Rate — One rate covering all members of the group regardless of their family status.
• Comprehensive Major Medical — Insurance plan that has a low deductible, high maximum benefits, and a coinsurance feature. A combination of basic coverage and major medical coverage that has replaced separate hospital, surgical and medical policies with each having its own deductible requirements. Also see Major Medical Insurance.
• Conditionally Renewable — Contract providing the insured may renew it to a stated date or an advanced age that is subject to the right of the insurer to decline renewal only under conditions as previously stated in the contract.
• Continuation — Terminated employees are allowed to continue their group health insurance coverage under certain conditions.
• Contract Year — The period running from effective date to expiration date of contract.
• Coordination of Benefits (COB) — Group policy provision that determines the primary carrier in situations when insured is covered by multiple policies. Prevents insured from receiving claims overpayments.
• Copay — Arrangement where covered person pays a specified amount for specified services and health care provider pays remainder. Covered person usually pays his or her share when service is rendered. Unlike coinsurance that is a percentage, co-payment is a dollar amount.
• Cost of Living Benefit — Optional disability benefit where monthly benefit is increased annually once insured is on claim for 12 months.
• Cost Sharing — Covered persons pay a portion of the health costs such as deductibles, coinsurance, or co-payment amounts.
• Covered Expenses — Health care expenses incurred by a covered person that qualify for reimbursement under a policy contract.
• Covered Person — Person who pays premiums to the contract for benefits provided and also meets eligibility requirements.
• Custodial Care — Care primarily for meeting personal needs such as assistance in bathing, dressing, eating or taking medicine. Can be provided by someone without professional medical training.

D

• Date of Service — The date health service was provided.
• Deductible Carryover Credit — During the last three months of calendar year, charges incurred for services can be applied the deductible for the following calendar year. Credits may be applied whether or not the prior calendar year’s deductible is met.
• Delete — The process of taking an individual off coverage.
• Dental Insurance — A Health Insurance contract that provides payment for specified dental services.
• Dependent Coverage — Insurance coverage on the head of a family which is extended to his or her dependents, including a spouse and unmarried children who are not yet employed on a full-time basis and are not full time students. “Children” may be step, foster, and adopted, as well as natural. Certain age restrictions on children usually apply.
• Designated Mental Health Provider — Organization hired by health plan to provide mental health and substance abuse services.
• Diagnosis — Disease identification.
• Diagnosis Related Groups (DRGs) — Classification of inpatient hospital services. Used as method of determining financing to reimburse providers for services performed.
• Disability Benefits Law — State law requiring employer to provide disability benefits to covered employees for non-occupational injuries. This is in contrast to Workers Compensation, which pays for occupational injuries. Laws are currently in effect in New York, New Jersey, Rhode Island, California, and Hawaii.
• Disability Income Insurance — Form of health insurance providing periodic payments to replace income, actual or presumed loss, when sickness of injury results in the insured being unable to work.
• Discharge Planning — Determination of the extent of patient’s medical needs after discharge from a hospital or other inpatient treatment.
• Dismemberment — Loss of, or loss of use of, specified members of the body resulting from accidental bodily injury.
• Dismemberment Benefit — Benefits payable for various types of dismemberment. See also Accidental Death and Dismemberment.
• Dread (or Specified) Disease Policy — Coverage, usually with a high maximum limit, for all of medical expenses as a result of diseases specified in the contract. Diseases covered include cancer, multiple sclerosis, poliomyelitis, spinal meningitis, diphtheria, and tetanus as well as others.
• Drug Formulary — Schedule of prescription drugs approved for use that will be covered by the plan. These are then dispensed through participating pharmacies.
• Drug Utilization Review (DUR) — Evaluation or review of the use of drugs in order to determine appropriateness of drug therapy.
• Duplication of Benefits — Identical or overlapping coverage exists between two or more insurance companies or service organizations. For use in applying the coordination of benefits provisions when two or more insurance companies are involved.

E

• Eligibility Date — Date a person becomes eligible for benefits.
• Eligibility Period — (1) Period of time during which potential members of a Group program may enroll without providing evidence of insurability. (2) Period of time under Major Medical policy during which reimbursable expenses may be accrued.
• Eligible Employee — Employee who is eligible based on the requirements detailed in the group contract.
• Eligible Expenses — Expenses, defined in the plan, which are eligible for coverage. May involve specified health services fees or “customary and reasonable charges.”
• Elimination Period — Sometimes designates the probationary period, but most often states the waiting period in a Health Insurance policy.
• Emergency — Injury or disease that happens suddenly and requires treatment within 24 hours.
• Employee Benefit Program — Benefits offered to an employee by his employer at his place of work, covering contingencies such as medical expenses, disability, retirement, and death, usually paid for wholly or in part by the employer. These benefits are usually insured.
• Employee Certificate of Insurance — Employee’s evidence of participation in a group insurance plan; a brief summary of plan benefits. The employee can be provided with a certificate of insurance in lieu of the actual insurance policy.
• Employee Contribution — Employee’s share of premium costs.
• Employer Contribution — Portion of the cost of a health insurance plan that is paid by the employer.
• Enrollee — Eligible individual enrolled in a health plan; does not include eligible dependent.
• Enrollment — Total number of enrollees in a health plan. May also be used to refer to the process of enrolling people in a health plan.
• Enrollment Period — Period in which an employee can sign up for health care or change plans.
• Evidence of Insurability — Statement of information needed for underwriting of an insurance policy.
• Expected Claims — Estimated claims for a person or group for a contract year based on actuarial statistics.
• Expected Morbidity — Expected incidence of sickness or injury within a group during a period of time as shown on a morbidity table.
• Experimental or Unproven Procedures — Health care services, drugs, supplies, procedures, therapies, or devices that the health plan determines to be either (1) not proven by scientific evidence to be effective, or (2) not accepted by health care professionals as being effective.
• Explanation of Benefits (EOB) — Statement sent to participant listing services, amounts paid by the plan, and total amount billed to the patient.
• Extended Care Facility — Facility, such as a nursing home, which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Three levels of care are defined as: skilled, intermediate, custodial, or any combination.

F

• Fee-for-Service Reimbursement — Health care system where physicians and providers receive payment based on billed charge for each service provided.
• Fee Schedule — List of maximum fees for providers on a fee-for-service basis.
• Field Underwriting — Initial screening “in the field” of prospective buyers of health insurance, performed by sales personnel. Also may include quoting of premium rates.
• Flexible Benefit Plan — Program where employees tailor their benefits to meet their specific needs.
• Frequency — Number of times a particular service is provided over a given time period.
• Funding Methods — Agreed means by which an employer pays for health coverage.

G

• Gatekeeper Model — Under this model of HMO and POS organizations, primary care physician (the gatekeeper) is the initial contact for the patient for medical care and for referrals. Also known as closed access or closed panel.
• Generic Drug — Drug that is exactly the same as a brand name drug and is allowed to be produced after the brand name drug’s patent has expired. Also known as “generic equivalent.”
• Grievance Procedure — Procedure allowing member of a health plan or provider of benefits to express complaints and seek remedies.
• Group Contract — Contract of insurance made with an employer or other entity covering a group of persons identified by their relationship to the entity buying the contract. Generally used to cover employees of a common employer, members of a trade association or trusteeship, members of a welfare or employee benefit association, members of a labor union, or members of a professional or other association not formed only for the purpose of obtaining insurance.
• Group Disability Insurance — Coverage provided for a group for loss of compensation due to accident or sickness.

H

• HMO — See Health Maintenance Organization.
• Home Health Agency — Certified facility approved by health plan to provide services.
• Home Health Care — Care received at home in the form of part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services of home health aides or help from homemakers or chore workers.
• Health History — Information used by underwriters to evaluate groups or individuals to determine the risk.
• Health Plan — Any kind of insurance plan against loss by sickness or bodily injury, covering health care services such as HMOs, insured plans, preferred provider organizations, etc.
• Health Maintenance Organization (HMO) — A prepaid medical service plan providing services to plan members. Providers contract with the HMO to provide medical services to members. Contracted providers must be used. Emphasis is on preventive medicine.
• Health Services — Benefits covered under a health contract.
• Hospice — Organization providing primarily pain relief, symptom management and supportive services for the terminally ill and their families.
• Hospital Affiliation — Contract with one or more hospitals agreeing to provide benefits to members of a specific health plan.
• Hospital Benefits — Benefits payable for hospital room and board, and miscellaneous charges as a result of hospitalization.
• Hospitalization Expense Policy — Policy covering daily hospital room and board charges and miscellaneous hospital expenses (such as X-ray, etc.). Often covers emergency treatment charges and may also include a surgical benefit.

I

• In-Area Services — Services provided within the “authorized” service area as specified in the plan.
• In-Force Business — Life or Health Insurance for which premiums are being paid or have been fully paid. Total premium volume of an insurer’s portfolio of business.
• Initial Eligibility Period — During this time period, prospective members can apply for coverage without providing evidence of insurability.
• Intentional Injury — Injury resulting from an act, the doer of which intended to inflict injury.
• Intermediate Care — Level of care associated with skilled nursing facility providing nursing care under the supervision of physicians or a registered nurse.
• Intermediate Care Facility — Facility licensed by the state providing nursing care to persons who do not require the degree of care provided by a hospital or skilled nursing facility.

L

• Large Claim Pooling — System designed to stabilize the premium fluctuation in small groups. Large claims are charged to a pool with contributions from many small groups who belong and share in the pool. The smaller the group of groups, the lower the pooling level. Conversely, larger groups will have a larger pooling level.
• Legend Drug — Drug with the following stated on its label “caution: federal law prohibits dispensing without a prescription.”
• Length of Stay (LOS) — Total number of days participant stays in care facility such as a hospital.
• Long Term Care (LTC) — Care provided for persons with chronic diseases or disabilities. Includes a range of health and social services provided under the supervision of medical professionals.
• Long Term Care Facility — State licensed facility providing skilled nursing services, intermediate care and custodial care.
• Long-Term Disability Insurance — Policy providing coverage for longer than a short term, usually until the insured reaches normal social security retirement age.
• Loss-Of-Income Benefits — Benefits paid as remuneration for inability to work due to disability resulting from accidental bodily injury or sickness.

M

• Major Medical Insurance — Health Insurance providing benefits up to a high limit for most types of medical expenses incurred, subject to a substantial deductible. Contracts may contain limits on specific types of charges, like room and board, and a percentage participation clause (coinsurance clause). Policies usually pay covered expenses whether an individual is in or out of the hospital.
• Managed Care — System of health care with the goal being a system delivering quality, cost effective health care through monitoring and recommending utilization of services, and cost of services.
• Mandated Benefits — State or federally required benefits.
• Mandated Providers — Medical care providers whose services must be included by state or federal law.
• Manual Rates — Rates based on average claims data for large number of groups. Rates are adjusted for specific groups based on a particular group’s characteristics, such as the type of industry, changes in benefits from the standard, etc.
• Maximum Allowable Costs (MAC) List — List of services where reimbursement is based on maximum scheduled cost.
• Maximum Out-of-Pocket Costs — Largest amount insured will pay considering co-payments, coinsurance, deductibles, etc.
• Medical Expense Insurance — Health Insurance providing benefits for medical, surgical, and hospital expenses. Includes coverage under the names Hospital-Surgical Expense Insurance and Medical Care Insurance.
• Medically Necessary — Service or treatment deemed absolutely necessary in treating a patient and the omission of such could adversely affect the patient’s condition.
• Member — Person covered under a health plan (enrollee or eligible dependent).
• Mental Health Services and Supplies — Required for treatment of mental illness, which include substance abuse and alcoholism.
• Minimum Premium — Cost plus arrangement with the employer paying the insurer only a portion of the premium which to be used for administration costs. Remainder is placed in a “bank account” and then used by the insurer to pay claims.
• Miscellaneous Expenses — Expenses, usually hospital charges other than daily room and board. Examples: X-rays, drugs, and lab fees. Total amount of these charges to be reimbursed is limited in most basic hospitalization policies.
• Morbidity Table — Table exhibiting incidence of sickness at specified ages in the same fashion that mortality table shows the incidence of death at specified ages.
• Multi-Disciplinary — Treatment involving care provided by a range of specialists.
• Multiple Option Plan — Employees optionally choose from a variety of offered plans.

N

• Non-cancelable (“Non-Can”) — Health Insurance contract where the insured has a right to continue in force by payment of premiums, as set forth in the contract, for a substantial period of time, also as specified in the contract. The insurer has no right to make any change in any provision of the contract, during that period of time.
• Non-disabling Injury — Injury not qualifying the insured for total or partial disability benefits.
• Non-duplication of Benefits — Provision in some policies specifying benefits will not be paid for amounts reimbursed by others. Often called coordination of benefits (COB).
• Non-Occupational Policy — Policy or provision of a policy excluding accidents that occur on the job, when such employment is covered by workers compensation.
• Nonparticipating Provider — 1) Provider who has not signed a contract with a health plan. 2) Medical or health care provider who is not certified to participate in the Medicare program.
• Nursing Home — Licensed facility providing general nursing care to the chronically ill or those unable to take care of necessary daily living needs. Also known as Long Term Care facility.

O

• Occupational Disease — Impairment of health, which has been caused by continued exposure to conditions inherent in a person’s occupation or a disease caused by employment or resulting from the nature of employment.
• Office Visit — Health care services provided in the physician’s office.
• Open Access — Also called open panel, allows participant to see another participating service provider without a referral.
• Open Enrollment Period — Period during which members elect to be included under an alternate plan, usually without providing evidence of insurability.
• Optionally Renewable — Contract in which an insurer reserves the unrestricted right to terminate coverage at any anniversary or at any premium due date.
• Out-of-Pocket Costs — Amounts insured must pay out of their own pocket, including such things as coinsurance, deductibles, etc.
• Out-of-Pocket Limit — Maximum coinsurance insured is required to pay, after which the insurer will pay 100% of covered expenses up to policy limit.
• Outpatient — One who is not a bed patient in the hospital in which they are receiving treatment.
• Over-The-Counter Drugs (OTC) — Drug that can be purchased without a prescription.

P

• Paid Claims. — Amounts paid to providers based on plan.
• Partial Disability — A condition as a result of injury or sickness when the insured cannot perform all of the duties of his occupation but a portion of them. Definition varies by policy.
• Participant — Employee or former employee eligible to receive benefits from an employee benefit plan or whose beneficiaries may be eligible to receive benefits from the plan.
• Participation — Number of employees enrolled compared to total eligible for coverage. Often, a minimum participation percentage is required.
• Permanent Partial Disability — Condition where the injured party’s earning capacity is impaired for life, but he can work at reduced efficiency.
• Permanent Total Disability — Condition where the injured party is unable to work at any gainful employment for balance of his lifetime.
• Physical Therapist — Trained medical person providing rehabilitative services and therapy to help restore bodily functions (walking, speech, the use of limbs, etc.).
• Place of Service — Where the actual services are performed. It may be home, hospital, office, clinic, etc.
• Point-of-Service Plan. — Plan allows choice of receiving services from a participating or from nonparticipating provider.
• Pre-Admission Authorization — Cost containment feature of group medical policies. The insured must contact the insurer prior to hospitalization and receive admission authorization.
• Preexisting Condition — Physical condition existing prior to the effective date of a policy. In many policies not covered until after a stated period of time has elapsed.
• Preferred Provider Organization (PPO) — Organization consisting of hospitals and physicians providing, for a set fee, services to insurance company clients. These are preferred providers and insured selects from any number of hospitals and physicians without being limited as with an HMO. Coverage is 100%, with a minimal co-payment for each office visit or hospital stay.

Q

• Qualifying Event — Occurrence (i.e. death, termination of employment, divorce, etc.) triggering insured’s protection under COBRA, that requires continuation of benefits under group insurance plan for former employees and their families who would otherwise lose coverage.
• Quality Assurance — Activities involving reviewing quality of services and taking any corrective actions to remove deficiencies.

R

• Rating Process — Steps used to determine premium rate for particular group based on amount of risk that group presents. Generally factored into the rating process are age, sex, type of industry, benefits, and administrative costs.
• Reasonable and Customary Charges — Charge for medical services referring to amount approved by a carrier for payment. Customary charges are defined as those most often made by a provider for services rendered in that particular area.
• Recidivism — How often a patient returns to an inpatient hospital status for the same reason.
• Recurring Clause — Health Insurance policy provision defining duration of time during which recurrence of a condition is considered a continuation of a prior period of disability or confinement.
• Referral — Physician or other health plan provider receives permission to consult another physician or hospital.
• Rehabilitation Clause — Clause in a Health Insurance policy intended to assist the disabled policyholder in vocational rehabilitation.
• Residual Disability — Form of disability defined as partial disability when an insured returns to work immediately following a period of total disability.
• Residual Income — Clause used with disability income policies providing benefits to be paid when the insured can do some but not all of their normal duties.
• Respite Care — Normally associated with Hospice care, a benefit to family members of a patient when the family is provided with a break from caring for the patient. Patient is confined to a nursing facility for needed care for a short period of time.
• Restoration of Benefits — Provision in Major Medical Plans restoring a person’s lifetime maximum benefit amount in small increments after a claim has been paid. Only a small amount ($1,000 to $3,000) usually may be restored annually.
• Retention — Portion of premium used by the insurance company for administrative costs.
• Return of Premium — Rider or provision in a disability policy agreeing to pay benefit equal to a percentage of premiums paid, minus claims paid.
• Risk Analysis — Process of determining benefits to be offered and premium to charge a particular group.

S

• Schedule — List of specified amounts or percentages payable for different health or dental procedures.
• Second Surgical Opinion — Cost containment technique to assist patients and insurance companies in determining whether a recommended procedure is necessary, or if an alternative method of treatment could accomplish the same result. Some health policies require a second opinion before procedures will be covered, and many policies pay for the second opinion.
• Secondary Care — Medical services provided by physicians not having first contact with patients. Examples include specialists such as urologists, cardiologists, etc.
• Self-Funded Plan — Insurance plan where an employer pays the claims rather than an insurance company.
• Self-Inflicted Injury — Bodily injury of the insured inflicted on himself.
• Service Area — Geographic area in which a health plan can provide services.
• Short-Term Disability Insurance — Group or individual policy written to cover disabilities of usually 13 or 26 weeks duration. However, coverage for as long as two years is not uncommon.
• Sickness — Including physical illness, disease, pregnancy, but not including mental illness.
• Skilled Nursing Care — Daily nursing and rehabilitative care performed only by or under supervision of skilled professional or technical personnel. Includes administering medication, medical diagnosis and minor surgery.
• Stop-Loss Insurance — Type of reinsurance taken out by a health plan or self-funded employer plan. Plan can be written to cover excess losses over a specified amount either on a specific or individual basis, or on a total basis for the plan over a period of time such as one year.
• Subscriber — Term has two meanings: 1) A person or organization who pays the premiums, and 2) person whose employment makes them eligible for membership in the plan.
• Subscriber Contract — Agreement describing individual’s benefits under a health care policy.
• Summary Plan Description — Recap or summary of benefits provided. Used most often with employees covered by self-funded plans.
• Supplemental Services — Additional services purchased over and above the basic coverage.
• Surgi-Center — Facility separate from a hospital providing outpatient surgical services.

T

• Terminally Ill — Term referring to status of a person who is anticipated to die within 6 months of a specific illness or sickness.
• Therapeutic Alternatives — Alternate drugs the chemical content of which may be different, but provide the same effect when administered to patients.
• Therapeutic Equivalence — Different drugs that control a symptom or illness in exactly the same manner as other drugs used to control that illness.
• Third Party Administrator (TPA) — Firm that administers group insurance policies for employers and other associations. In addition to being the liaison between the employer and the insurer, the TPA is involved with certifying eligibility, preparing reports required by the state and processing claims. Use of TPA’s has increased with the growth of employer self-funded plans.
• Third-Party Payor — Refers to any organization such as Blue Cross/ Blue Shield, Medicare, Medicaid, or commercial insurance companies that are payers for coverage provided by a health plan.
• Total Disability — Degree of disability from injury or sickness preventing the insured from performing the duties of any occupation for remuneration or profit. Definition in each specific case depends on the wording in the covering policy.
• Travel Accident Insurance — Health Insurance limiting coverage to accidents occurring while the insured is traveling.
• Treatment Facility — Residential or nonresidential facility authorized to provide treatment for mental illness or substance abuse.
• Triage — Ranking method of sick or injured people according to the severity of sickness or injury to ensure medical and nursing staff facilities are used most efficiently.

U

• Uniform Premium — Rating system used to calculate premiums for all insureds without distinctions as to age, sex or occupation.
• Utilization — How much a covered group uses a particular plan or program.
• Utilization Management — Procedure or process utilizing a review coordinator to evaluate necessity and appropriateness of various health care services.
• Utilization Review — Cost control mechanism monitoring by insurers and employers the appropriateness, necessity, and quality of health care.

W

• Waiting Period — Period of time between the beginning of a disability and the start of Disability Insurance benefits. Also known as the elimination period.