Glossary of Insurance Terms
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Date of Service
The date that the health service was provided.
Deductible
The amount of money you must pay each year to cover your medical care expenses
before your insurance policy starts paying.
Deductible Carryover
Credit
During the last three months of a calendar year, charges incurred for health
services can be used to satisfy the deductible for the following calendar
year. These credits may be applied whether or not the prior calendar year's
deductible had been met.
Department of Health
and Human Services
A federal department whose responsibility is primarily dealing with social
service functions such as administration and supervision of the Medicare program.
Dependent Coverage
Insurance coverage on the head of a family which is extended to his or her
dependents, including only the lawful spouse and unmarried children who are
not yet employed on a full-time basis. "Children" may be step, foster,
and adopted, as well as natural. Certain age restrictions on children usually
apply.
Designated Mental Health
Provider
The organization hired by a health plan to provide mental health and substance
abuse services.
Diagnosis Related
Groups (DRGs)
A method of classifying inpatient hospital services. It is used as a method
of determining financing to reimburse various providers for services performed.
Drug formulary
List of preferred pharmaceutical products to be used by a managed care plan's
network physicians. Formularies are based on evaluations of the efficacy,
safety, and cost-effectiveness of drugs.
Drug Utilization Review
(DUR)
A method for evaluating or reviewing the use of drugs in order to determine
the appropriateness of the drug therapy.
Duplication of Benefits
A situation where identical or overlapping coverage exists between two or
more insurance companies or service organizations.
Durable medical equipment
(DME)
Items such as iron lungs, oxygen tents, hospital beds, wheelchairs, and seat
lift mechanisms which are used in the patient's home and are either purchased
or rented.
ERISA
See Employee Retirement Income Security Act. (H,LI)
Eligibility Date
The date that a person is eligible for benefits.
Eligibility Period
Time following the eligibility date (usually 31 days) during which a member
of a group may apply for insurance without evidence of insurability.
Eligibility Requirements
Requirements imposed for eligibility for coverage, usually in a group insurance
or pension plan.
Eligible Dependent
A dependent of an insured person who is eligible for coverage according to
the requirements set forth in the contract.
Eligible Employee
An employee who is eligible based on the requirements as indicated in the
group contract.
Eligible Expenses
Expenses as defined in the health plan as being eligible for coverage. This
could involve specified health services fees or "customary and reasonable
charges."
Eligible Person
Similar to eligible employee except it could be a contract covering people
who are not employees of a specified employer. An example might be members
of an association, union, etc.
Employee Certificate
of Insurance
The employee's evidence of participation in a group insurance plan, consisting
of a brief summary of plan benefits. The employee is provided with a certificate
of insurance rather than the actual insurance policy.
Employee Contribution
The employee's share of the premium costs.
Employer Contribution
The portion of the cost of a health insurance plan which is borne by the employer.
Enrollee
An eligible individual who is enrolled in a health plan _ does not include
an eligible dependent.
Enrollment
Used to describe the total number of enrollees in a health plan. It may also
be used to refer to the process of enrolling people in a health plan.
Enrollment Card
Document signed by an eligible person indicating a desire to participate in
a group insurance plan. The document or card authorizes an employer to deduct
contributions from an employee's pay. If life and accidental death and dismemberment
coverage are involved, the card usually includes the beneficiary's name and
relationship.
Enrollment Period
The amount of time an employee has to sign up for a contributory health plan.
Evidence of Coverage
See Certificate of Coverage.
Evidence of Insurability
A statement or proof of physical condition and/or other factual information
affecting a person's eligibility for insurance. In group insurance, evidence
of insurability is required only in specific situations, such as when a person
fails to enroll during the open enrollment period, when a person applies for
reinstatement after having previously withdrawn from the plan when receiving
an overall maximum benefit, or when a person applies for excess amounts of
group life or disability insurance.
Examination
The medical examination of an applicant for Life or Health insurance.
Exclusions
Exclusions are specific conditions or circumstances for which the policy will
not provide benefits.
Exclusive Provider
Organization (EPO)
A type of preferred provider organization where individual members use particular
preferred providers rather than having a choice of a variety of preferred
providers. EPOs are characterized by a primary physician who monitors care
and makes referrals to a network of providers.
Experimental or Unproven Procedures
Any health care services, supplies, procedures, therapies, or devices that
the health plan determines regarding coverage for a particular case to be
either (1) not proven by scientific evidence to be effective, or (2) not accepted
by health care representatives as being effective.
Explanation of Benefits
(EOB)
The statement sent to a participant in a health plan listing services, amounts
paid by the plan, and total amount billed to the patient.
Extended Coverage
A provision in certain Health policies, usually Group, to allow the insured
to receive benefits for specified losses sustained after the termination of
coverage, such a maternity expense benefits incurred for a pregnancy in progress
at the time of the termination.
Extension of Benefits
A condition in the insurance policy which allows coverage to continue beyond
the expiration date of the policy in the case of employees who are not actively
at work or dependents who are hospitalized on that date. The extended coverage
applies only where the employee or dependent is disabled as of that date and
continues only until the employee returns to work or the dependent leaves
the hospital.
Federal Qualification
Approval of any HMO made by the HCFA after conducting their evaluation of
methods of doing business, documents, contracts, facilities, and systems.
Fee-for-Service
A payment system for health care where the provider is paid for each service
rendered rather than a pre-negotiated amount for each patient.
Fee Maximum
The maximum amount available to a provider for specific health care services
under a contract.
Fee Schedule
A list of maximum fees for providers who are on a fee-for-service basis.
Field Underwriting
The initial screening of prospective buyers of health insurance, performed
by sales personnel "in the field." May also include quoting of premium
rates.
Financial Accounting
Standards Board (FASB)
A non-governmental group that sets standards for generally accepted accounting
principles.
Flat Maternity Benefit
A stipulated benefit in a Hospital Reimbursement policy that is paid for maternity
confinement, regardless of the actual cost of the confinement.
Flexible Benefit Plan
A type of program where employees can tailor their benefits to meet their
own specific needs.
Formulary
List of preferred pharmaceutical products to be used by a managed care plan's
network physicians. Formularies are based on evaluations of the efficacy,
safety, and cost-effectiveness of drugs.
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