Health Insurance Glossary
- 24 Hour Approval:
- "24 Hour Approval" is a special feature offered on some health insurance plans. When you apply for coverage under plans offering "24 Hour Approval", you can be advised via email of the insurance company's coverage decision within 24 hours.
- How It Works:
-
- 1) Apply online for a health insurance plan with this symbol.
- 2) Complete and submit the application online through our website.
- 3) The insurance company will then review your application and you can receive an update within 24 hours on whether you are approved; though in some cases you may receive a status update or request for further information instead. Depending on whether the insurance company needs more information, when you submit your application or other conditions, some exceptions may apply.
- 1) Apply online for a health insurance plan with this symbol.
- Access:
- The availability of medical care. The quality of one's access to medical care is determined by location, transportation options, and the type of medical care facilities available in the area, etc..
- Accident:
- For health insurance purposes, an accident is an unforeseen, unexpected and unintended event resulting in bodily injury.
- Accumulation Period:
- The period of time during which an insured person incurs eligible medical expenses toward the satisfaction of a deductible.
- Actively-at-work:
- Most group health insurance policies state that if an employee is not "actively-at-work" on the day the policy goes into effect, the coverage will not begin until the employee returns to work.
- Actual Charge:
- The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.
- Actuary:
- A person professionally trained in the mathematical and statistical aspects of the insurance industry.
Actuaries frequently calculate premium rates, reserves and dividends and assist in estimating the costs and savings of benefit changes.
- Acupuncture:
- Typicablly, acupuncture services include services performed by a licensed acupuncturist.
- Acute Care:
- Medical care administered, frequently in a hospital or by nursing professionals, for the treatment of a serious injury or illness or during recovery from surgery. Medical conditions requiring acute care are typically periodic or temporary in nature, rather than chronic.
- Additional Drug Benefit List:
- see Drug Maintenance List.
- Administrative Services Only (ASO) Agreement:
- A business contract under which an insurance company agrees to perform specific administrative duties for the maintenance of a self-funded health insurance plan.
- Admissions/1,000:
- A statistic used by health insurance companies describing the number of hospital admissions for each 1000 persons covered under a health insurance plan within a given time period.
- Admits:
- Hospital admissions. A term used to describe the number of persons admitted to a hospital within a given period.
- Adverse Selection:
- The tendency of those who experience greater health risks to apply for and continue their coverage under any given health insurance plan. When adverse selection increases, health insurance companies experience greater expenses and may raise rates.
- Age Change:
- For insurance purposes, this is the date on which a person's age changes. Note that this may not correspond with the individual's actual birthday, but may fall midway between birthdays. An age change may result in an increase in rates.
- Age Limits:
- Ages below and above which an insurance company will not accept applications or renew policies.
- Age/Sex Factor:
- A factor employed by insurance companies in the underwriting process, used to determine a group's risk of incurring medical costs, based on the ages and genders of the persons in that group.
- Agent:
- A state-licensed individual or entity representing one or more insurance companies. An agent solicits and facilitates the sale of insurance contracts or policies and provides services to the policyholder on behalf of the insurer. See also, Broker.
- Allied Health Personnel:
- Also referred to as paramedical personnel, these are health workers (often licensed) who perform duties that would otherwise be performed by physicians, optometrists, dentists, podiatrists, nurses and chiropractors.
- Allowable Charge:
-
-also referred to as the Allowed Amount,
Approved Charge or Maximum Allowable. See also,
Usual, Customary and Reasonable Charge. This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers.
The Allowable Charge is typically a discounted rate rather than the actual charge. It may be helpful to consider an example: You have just visited your doctor for an earache. The total charge for the visit comes to $100. If the doctor is a member of your health insurance company's
network of providers, he or she may be required to accept $80 as payment in full for the visit - this is the Allowable Charge. Your health insurance company will pay all or a portion of the remaining $80, minus any co-payment or deductible that you may owe. The remaining $20 is considered provider write-off. You cannot be billed for this provider write-off. If, however, the doctor you visit is not a network provider then you may be held responsible
for everything that your health insurance company will not pay, up to the full charge of $100.
This term may also be used within a Medicare context to refer to the amount that Medicare considers payment in full for a particular, approved medical service or supply.
- Allowable Costs:
- Charges for healthcare services and supplies for which benefits are available under your health insurance plan.
- Allowed Amount:
- -see Allowable Charge.
- Alternate Delivery System:
- Healthcare services or facilities which "deliver" care that is more cost-effective than that provided in a hospital. Alternate Delivery Systems may include skilled nursing facilities, hospice programs and home health care services.
- Alternative Medicine:
- Any medical practice of form of treatment not generally recognized as effective by the medical community at large. Alternative medicine may encompass a broad range of services and practices including acupuncture, homeopathy, aromatherapy, naturopathy, etc.. Many insurance companies do not provide coverage for these services.
- Ambulatory Care:
- Medical care rendered on an outpatient basis and which may include diagnosis, certain forms of treatment, surgery and rehabilitation. See also, Ambulatory Setting.
- Ambulatory Setting:
- Medical facilities such as surgery centers, clinics and offices in which healthcare is provided on an outpatient basis.
- Ancillary Fee:
- An extra fee sometimes associated with obtaining prescription drugs which are not listed on a health insurance plan's formulary of covered medications.
- Ancillary Products:
- Additional health insurance products (such as vision or dental insurance) that may be added to a medical insurance plan for an additional fee.
- Ancillary Services:
- Supplemental healthcare services such as laboratory work, x-rays or physical therapy that are provided in conjunction with medical or hospital care.
- Annual limit:
- Many health insurance plans place dollar limits upon the claims the insurer will pay over the course of a plan year. Beginning September 23, 2010, PPACA phases annual dollar limits will be phased out over the next 3 years until 2014 when they will not be permitted for most plans. There is an exception to this phase out for Grandfathered Plans. Except for Grandfathered Plans, beginning September 23, 2012 annual limits can be no lower than $2 million. Except for Grandfathered Plans, beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited.
- Application Fee:
- The health insurance company may require a one-time application fee. Some insurance companies may refund this fee if the application is not approved. See More Insurance Plan Details section for additional information.
- Approved Charge:
- -see Allowable Charge.
- Approved Health Care Facility or Program:
- A medical facility or healthcare program (often organized through a hospital or clinic) that has been approved by a health insurance plan to provide specific services for specific conditions.
- Assignment of Benefits:
- The payment of health insurance benefits to a healthcare provider rather than directly to the member of a health insurance plan.
- Attending Physician Statement (APS):
- A physician's assessment of a patient's state of health as outlined in office notes and test results compiled by the physician. An APS may be requested by an insurance company in lieu of a medical examination in order to determine the state of a health insurance applicant's health for underwriting purposes.
please note, however, that definitions of certain terms may vary across insurance companies.
eHealthInsurance is the nation's leading online source of health insurance. eHealthInsurance offers thousands of health plans underwritten by more than 180 of the nation's health insurance companies, including Aetna and Blue Cross Blue Shield. Compare plans side by side, get health insurance quotes, apply online and find affordable health insurance today.
