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Glossary of Insurance Terms

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Schedule (Surgical)
A list of specified amounts payable for surgical procedures, dismemberments, ancillary expenses, and the like in hospital and medical reimbursement policies.

Second Surgical Opinion
A cost containment technique to help patients and insurance companies determine whether a recommended procedure is necessary, or whether an alternative method of treatment could accomplish the same result. Some health policies require a second surgical opinion before specified procedures will be covered, and many policies pay for the second opinion.

Secondary Care
Medical services provided by physicians who do not have first contact with patients. Examples would be specialists such as urologists, cardiologists, etc. See also Primary Care and Tertiary Care.

Secondary Coverage
Coverage which provides payment for charges not covered by the primary policy or plan. See also Coordination of Benefits.

Section 125 Plan
A plan which provides flexible benefits. This plan qualifies under the IRS code which allows employee contributions to meet with pre-tax dollars.

Self-Funded Plan
Plan of insurance where an employer, which has fairly predictable claim costs, pays the claims rather than an insurance company. See also Administrative Services Only.

Self-Inflicted Injury
An injury to the body of the insured inflicted by himself.

Service Area
The area, allowed by state agencies or by the certification of authority, in which a health plan can provide services.

Service Plans
Plans of insurance where benefits are the actual services rendered rather than a monetary benefit.

Short-term plans
Short-term plans are similar to standard, individual and family health plans, except they are designed to provide coverage for only 1 to 6 months.

Skilled Nursing Care
Daily nursing and rehabilitative care that is performed only by or under the supervision of skilled professional or technical personnel. Skilled care includes administering medication, medical diagnosis and minor surgery.

Social Health Maintenance Organization (SHMO)
A demonstration project funded by the Health and Human Services Department that combines the delivery of acute and long term care with adult day care services and transportation.

Social Security Tax
A tax paid by workers and employers on wages earned. The taxes support the benefit programs under the Social Security System.

Staff Model HMO
This is an HMO where physicians are employed and all premiums are paid to the HMO, which then compensates the physicians on a salary and bonus arrangement.

Stop-Loss Insurance
This is a type of reinsurance which can be taken out by a health plan or self-funded employer plan. The 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.

This term has two meanings _ first, it refers to a person or organization who pays the premiums, and second, the person whose employment makes him or her eligible for membership in the plan.

Subscriber Contract
An agreement which describes the individual's benefits under a health care policy.

Summary Plan Description
This is a recap or summary of the benefits provided under the plan. It is used most often with employees covered by self-funded plans.

Supplementary Medical Insurance (SMI)
The Medicare program which pays for a portion of the costs of physician's services, outpatient hospital services, and other related medical and health services for voluntarily insured aged and disabled individuals. Also known as Part B.

Surgical Schedule
Usually part of a basic medical expense plan which itemizes various surgical procedures and the monetary benefit allocated to each procedure.

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
This act defines the primary and secondary coverage responsibilities of the Medicare program and also the provisions to be used by health plans in their contracts with the HCFA (Health Care Financing Administration).

Temporary Partial Disability
A condition where an injured party's capacity is impaired for a time, but he is able to continue working at reduced efficiency and is expected to fully recover.

Temporary Total Disability
A condition where an injured party is unable to work at all while he is recovering from injury, but he is expected to recover.

Tertiary Care
Services provided by such providers as thoracic surgeons, intensive care units, neurosurgeons, etc.

Terminally Ill
A term which refers to the status of a person who will normally die within 6 months of a specific illness or sickness. Often refers to the terminally ill requirement for hospice care.

Therapeutic Alternatives
Alternate drug products which may be different in chemical content, but provide the same effect when administered to patients.

Therapeutic Equivalence
Different drugs which will control a symptom or illness exactly the same as other drugs used to control that illness.

Third Party Administrator (TPA)
A firm which provides administrative services for employers and other associations having group insurance policies.

Time Limit on Certain Defenses
One of the uniform individual accident and sickness provisions required by state law to be included in every Individual Health Policy. It sets a limit on the number of years after a policy has been in force that an insurer can use as a defense against a claim the fact that a physical condition of the insured existed before the policy was issued, but was not declared at that time.

Treatment Facility
Any facility, either residential or nonresidential, which is authorized to provide treatment for mental illness or substance abuse.

Trend Factor
The factor applied to rates which allows for such changes as increased cost of medical providers, the cost of new and expensive medical technology, etc.

A method of ranking sick or injured people according to the severity of their sickness or injury in order to ensure that medical and nursing staff facilities are used most efficiently.

Triple Option
A plan where employees have their choice, among different types of provides such as HMO, PPO, or basic indemnity plan. Usually, their choice depends on how much they want to pay for the coverage.

Process by which an insurer determines whether or not, and on what basis, it will accept an application for insurance.

Uniform Billing Code of 1992 (UB-92)
This code is scheduled to be implemented on October 1, 1993. It's a federal directive which states how a hospital must provide their patients with bills, itemizing all services included and billed on each invoice.

Uniform Premium
A rating system that is used to calculate premiums for all insureds with no distinctions as to age, sex or occupation.

Uniform Provisions
A set of provisions regarding the operating conditions of individual Health policies developed in a model law recommended by the National Association of Insurance Commissioners and required, with minor variations by almost all jurisdictions, and permitted in all jurisdictions.

High-risk persons who do not have health care coverage through private insurance and who fall outside the parameters of risks of standard health underwriting practices.

Usual, Customary, and Reasonable (UCR)
See Reasonable and Customary.

This refers to how much a covered group uses a particular health plan or program.

Utilization and Review Committee
A committee composed of medical personnel whose purpose it is to monitor the health care services and supplies provided to Medicare patients.

Utilization Management
This procedure or process utilizes a review coordinator to evaluate the necessity and appropriateness of various health care services.

Utilization Review
A cost control mechanism by which the appropriateness, necessity, and quality of health care is monitored by both insurers and employers.

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