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Glossary of Insurance Terms

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MSA (Medical Savings Account)
A tax-advantaged personal savings account used in conjunction with a high deductible health policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses, including annual deductibles and copayments.

Major Hospitalization Policy
The same as Major Medical Insurance, except that it applies to expenses incurred only when the insured is hospitalized. See also Major Medical Insurance.

Major Medical Insurance
A type of Health Insurance that provides benefits up to a high limit for most types of medical expenses incurred, subject to a large deductible. Such contracts may contain limits on specific types of charges, like room and board, and a percentage participation clause sometimes called a coinsurance clause. These policies usually pay covered expenses whether an individual is in or out of the hospital.

Managed Care
A system of health care where the goal is a system that delivers quality, cost effective health care through monitoring and recommending utilization of services, and cost of services.

Managed Care Organization (MCO)
An umbrella term for health plans that provide health care in return for a set monthly payment and coordinate care through a network of physicians and hospitals. Health maintenance organizations and point-of-service plans are managed care organizations.

Manual Rates
Rates based on average claims data for a large number of groups. These rates are then adjusted for specific groups based on that group's characteristics, such as the type of industry, changes in benefits from the standard, etc.

Maximum Allowable Costs (MAC) List
A list of prescriptions where the reimbursement will be based on the cost of the generic product.

Maximum Out-of-Pocket Costs
The most a member will pay considering copayments, coinsurance, deductibles, etc.

Managed Care Organization
A general term for health plans that provide health care in return for pre-set monthly payments and coordinate care through a defined network of primary care physicians and hospitals.

Medical Expense Insurance
A form of Health Insurance that provides benefits for medical, surgical, and hospital expenses. This term is used to include coverage under the names Hospital-Surgical Expense Insurance and Medical Care Insurance.

Medical Information Bureau (MIB)
A data pool service that stores coded information on the health histories of persons who have applied for insurance from subscribing companies in the past. Most Life and Health insurers subscribe to this bureau to get more complete underwriting information.

Medical Loss Ratio
Total health benefits divided by total premium.

Medical Supplies
Any items which are essential in carrying out the treatment of a patient's illness or injury.

Medically Necessary
A service or treatment which is absolutely necessary in treating a patient and which could adversely affect the patient's condition if it were omitted.

A state-funded health care program for low income or disabled persons.

A nationwide, federally administered health insurance program authorized in 1965 to cover the cost of hospitalization, medical care, and some related services for most people over age 65. In 1972, coverage was extended to people receiving Social Security Disability Insurance payments for 2 years, and people with ESRD. Medicare consists of two separate but coordinated programs-Part A (hospital insurance, HI) and Part B (supplementary medical insurance, SMI). Almost all persons aged 65 or over or disabled entitled to HI are eligible to enroll in the SMI program on a voluntary basis by paying a monthly premium. Health insurance protection is available to Medicare beneficiaries without regard to income.

Medicare Beneficiary
Anyone entitled to Medicare benefits based on the designation by the Social Security Administration.

An expanded set of options for the delivery of health care under Medicare established by the Balanced Budget Act of 1997. Most Medicare beneficiaries can choose to receive benefits through the original fee-for-service program or through one of the following Medicare+Choice plans (1) coordinated care plans (such as health maintenance organizations, provider sponsored organizations, and preferred provider organizations); (2) Medical Savings Account (MSA)/High Deductible plans (through a demonstration available to up to 390,000 beneficiaries); or (3) private fee-for-service plans.

Medicare Economic Index (MEI)
An index which is often used in the calculation of the increases in the prevailing charge levels that help to determine allowed charges for physician services. In 1992 and later, this index is considered in connection with the update factor for the physician fee schedule.

Medicare Supplement Insurance
Insurance coverage sold on an individual or group basis which helps to fill the gaps in the protection provided by the Medicare program. Medicare supplements cannot duplicate any benefits provided by Medicare, but may pay part or all of Medicare's deductibles and copayments, and may cover some services and expenses not covered by Medicare.

Anyone covered under a health plan (enrollee or eligible dependent).

Mental Health Services and Supplies

Items required for treatment of mental illness, including substance abuse and alcoholism.

Minimum Premium
A cost plus arrangement whereby the employer pays the insurer only a portion of the premium which is to be used for administration costs. The remainder is placed in a "bank account" which is then used by the insurer to pay claims.

Miscellaneous Expenses
Ancillary expenses, usually hospital charges other than daily room and board. Examples would be X-rays, drugs, and lab fees. The total amount of such charges that will be reimbursed is limited in most basic hospitalization policies.

Modified Community Rating
A method of determining rates for medical services based on data from a given geographic area.

Modified Fee-For-Service
A situation where reimbursement is made based on the actual fees subject to maximums for each procedure.

National Association of Insurance Commissioners (NAIC)
National organization of state officials charged with regulating insurance. It has no official power, but wields significant influence. NAIC was formed to provide national uniformity in insurance regulations.

National Drug Code (NDC)
A system for identifying drugs.

A health insurance policy that 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 set forth in the contract. During that period of time, the insurer has no right to make any change in any provision of the contract.

Nonduplication of Benefits
A provision in some health insurance policies specifying that benefits will not be paid for amounts reimbursed by others.

Nursing Home
A licensed facility which provides general nursing care to those who are chronically ill or unable to take care of necessary daily living needs.

Open Enrollment Period
A period during which members can elect to come under an alternate plan, usually without providing evidence of insurability.

Optional Renewable Policy

Contract that grants the insurer the right to terminate a policy on any anniversary, or, in some cases, on a premium date.

Out-of-Network Care
Medical services obtained by managed care plan members from unaffiliated or on contracted health care providers. In many plans, such care will not be reimbursed unless previous authorization for such care is obtained.

Out-of-Pocket Costs
Health care costs the covered person must pay out of his or her own pocket, including such things as coinsurance, deductibles, etc.

Out-of-Pocket Maximum
The most money you will be required to pay in a year for deductibles and coinsurance in addition to regular premiums.

A patient who is not a bed patient in the hospital in which he or she is receiving treatment.

Over-The-Counter Drugs (OTC)
A drug that can be purchased without a prescription.

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