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: Usually refers to a policy with a high deductible.

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

Certificate of Insurance: 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. http://www.cchp.org/index.cfm?action=home&language=eng

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

COBRA: Acronym 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/dol/topic/health-plans/cobra.htm

Co-insurance: The percentage of each claim above the deductible paid by the policyholder. For a 20-percent health insurance co-insurance clause, the policyholder pays for the deductible plus 20 percent of their 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 assists 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/healthmainpage.htm

Co-payment: A specified dollar amount that you must pay out-of-pocket for a specified service at the time the service is rendered ( e.g. $40 per office visit, $75 per emergency room visit, or $10 per generic prescription).

CoverColorado: A nonprofit 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 for.

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

Disability Insurance: Pays you an income when your are unable to work because of an accident or illness.

Effective Date: The date your insurance coverage will actually begin on to cover you.

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

Fee-for-Service: The fee determined by your 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 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.

Guaranteed-Acceptance (-Issue): No medical questions/exams required.

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 the 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: Acronym for Health Maintenance Organization. An HMO’s is a prepaid, health benefit program whereby 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 that are members of your HMO plan's network.

HSA: Acronym for Health Savings Account operating somewhat like IRAs. An HSA is a tax-advantaged savings account for health care services. You must enroll in a qualified High-Deductible Health Plan (HDHP) before you can establish an HSA.

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

In-Network: Healthcare facilities or providers that are members of your health plan.

Lifetime Limit: The cap (or maximum level) on benefits available through your policy.

Limited Medical (Core Health Insurance): plans provide specific benefit amounts for specific medical care expenses due to an accident or sickness. Any costs incurred in excess of the stated benefit amount are the responsibility of the insured. Please review the plan benefits and limitations and exclusions to determine if they meet your needs.

Major Medical: plans typically cover a broad range of healthcare needs and are usually effective in covering serious illness or injury where health care costs are high. Major medical plans usually have a set amount, or deductible, for which the patient is responsible. Once that is paid, the plan covers most of the remaining cost of care, subject to co-pays or co-insurance paid by the patient.

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: Refers to an increasingly broad assortment of health plans that manage healthcare costs and usage. There are three major types of managed health plans: HMO (Health Maintenance Organization), POS (Point-Of-Service plan). Organizations), PPO (Preferred Provider Organizations).

Medicaid: A federal/state public-assistance program created in 1965 and state administered for people whose income and resources are insufficient to pay for health care.

Medicare: Federal program for people aged 65 or older that pays part of the costs associated with hospitalization, surgery, doctors’ bills, home health care, and skilled-nursing care. Below are some useful websites:

www.medicare.gov/coverage/Home.asp www.bouldercounty.org/cs/ag/programs/medicare.htm www.cfmc.org/consumers/consumers_resources.htm

Network: The groups of doctors, hospitals and other medical professionals who have been contracted to provide discounted healthcare services to your insurer’s customers.

Out-of-Network: 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 plan's guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.

POS: Acronym for Point-of-Service plan healthcare option that allows members to choose at the time medical services are needed whether you will go to a provider within the plan's network or seek medical care outside the network.

Pre-existing Conditions: 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.

PPO: An acronym for Preferred Provider Orgaization. A PPO is 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 your PPO network.

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

Premium: The price of your 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: Any individual (nurse, physician, or specialist) or institution (clinic, hospital, or laboratory) that provides you with care.

Rate-Up: 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: Purchased to provide you with healthcare benefits during coverage gaps between jobs, after a move, or while you're traveling overseas.

Small-Business Health Insurance: Available to businesses employing between 2 and 50 employees. It offers discounted premiums to employees and tax advantages to smal-business owners. In most cases, this coverage cannot be denied.

Travel Health Insurance: Covers health care and problems associated with traveling, that may include trip cancellation due to illness, lost luggage and other incidents.

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