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TERM

DEFINITION

Access

The availability of medical care to a patient. This can be determined by location, transportation, type of medical services in the area, etc. (H)

Accidental Death and Dismemberment

A policy or a provision in a Disability Income policy which pays either a specified amount or a multiple of the weekly disability benefit if the insured dies, loses his or her sight, or loses two limbs as the result of an accident. A lesser amount is payable for the loss of one eye, arm, leg, hand, or foot. (H)

Accrete

A Medicare term which means the process of adding new members to a health plan. (H)

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 does return to work. (H)

Activities of Daily Living (ADL)

Everyday living functions and activities performed by individuals without assistance. These functions would include mobility, dressing, personal hygiene and eating. (H)

Activities of Daily Living (ADL) Standards

Used to assess the ability of an individual to live independently, measured by the ability to perform unaided such activities as eating, bathing, toiletry, dressing, and walking. ADL standards are sometimes discussed as a way to measure or define eligibility for long term care. (H)

Actual Charge

The actual amount charged by a physician for medical services rendered. (H)

Acute Care

Skilled, medically necessary care provided by medical and nursing personnel in order to restore a person to good health. (H)

Adult Day Care

A group program for functionally impaired adults, designed to meet health, social and functional needs in a setting away from the adult's home. (H)

Aftercare

Individualized patient services required after hospitalization or rehabilitation. (H)

Agent

a licensed individual who represents several insurance companies and sells their products.

Allied Health Personnel

Health personnel who perform duties which would otherwise have to be performed by physicians, optometrists, dentists, podiatrists, nurses, and chiropractors. Also called paramedical personnel. (H)

Alzheimer's Disease

A progressive, irreversible disease characterized by degeneration of the brain cells and severe loss of memory causing the individual to become dysfunctional and dependent upon others for basic living needs. (H)

Ambulatory Care

Similar to outpatient treatment in that it is care which does not require hospitalization. (H)

Ambulatory Setting

Institutions such as surgery centers, clinics, or other outpatient facilities which provide health care on an outpatient basis. (H)

Ancillary

Additional services (other than room and board charges) such as X-rays, anesthesia, lab work, etc. Fees charged for ancillary care such as X-rays, anesthesia, and lab work. This term may also be used to describe the charge made by a pharmacy for prescriptions which exceed the health insurance plan's maximum allowable cost (MAC). (H)

Ancillary Benefits

Benefits for miscellaneous hospital charges. (H)

Approved Charge

Amounts paid under Medicare as the maximum fee for a covered service. (H)

Approved Health Care Facility or Program

A facility or program which has been approved by a health care plan as described in the contract. (H)

Assignment

An authorization to pay Medicare benefits directly to the provider. Medicare payments may be assigned to participating providers only. (H)

Assignment of Benefits

A method where the person receiving the medical benefits assigns the payment of those benefits to a physician or hospital. (H)

Average Length of Stay (ALOS)

The total number of patient days divided by the number of admissions and discharges during a specified period of time. This gives the average number of days in the hospital for each person admitted. (H)

Basic Hospital Expense Insurance

Hospital coverage providing benefits for room and board and miscellaneous hospital expenses for a specified number of days during hospital confinement. (H)

Bed Days/1,000

The number of inpatient hospital days per 1,000 members of the health plan. (H)

benefit

reimbursement for covered medical expenses as specified by the plan.

Benefit Levels

The maximum amount a person is entitled to receive for a particular service or services as spelled out in the contract with a health plan or insurer. (H)

Benefit Package

A description of what services the insurer or health plan offers to those covered under the terms of a health insurance contract. (H)

Benefit Period

Defines the period during which a Medicare beneficiary is eligible for Part A benefits. A benefit period is 90 days which begins the day the patient is admitted to a hospital and ends when the individual has not been hospitalized for a period of 60 consecutive days. (H)

Billed Claims

The amounts submitted by a health care provider for services provided to a covered individual. (H)

Birthday Rule

One method of determining which parent's medical coverage will be primary for dependent children: the parent whose birthday falls earliest in the year will be considered as having the primary plan. (H)

Blanket Insurance

A contract of Health Insurance that covers all of a class of persons not individually identified in the contract. (H)

Blanket Medical Expense

A policy or provision in a Health Insurance contract that pays all medical costs, including hospitalization, drugs, and treatments, without limitation on any item except possibly for a maximum aggregate benefit under the policy. It is often written with an initial deductible amount. (H)

Blue Cross

Blue Cross plans are nonprofit hospital expense prepayment plans designed primarily to provide benefits for hospitalization coverage, with certain restrictions on the type of accommodations to be used. (H)

Blue Plan

A generic designation for those companies, usually writing a service rather than a reimbursement contract, who are authorized to use the designation Blue Cross or Blue Shield and the insignia of either. (H)

Blue Shield

Blue Shield plans are prepayment plans offered by voluntary nonprofit organizations covering medical and surgical expenses. (H)

Board Certified

A physician or other professional who has passed an examination which certifies him or her as a specialist in a particular medical area. (H)

Board Eligible

A professional person or physician who is eligible to take a specialty examination. (H)

brand-name drug

prescription drug which is marketed with a specific brand name by the company that manufactures it. May cost insured individuals a higher co-pay than generic drugs on some health plans. (see "generic.")

broker

a licensed insurance professional who obtains multiple quotes and plan information in the interest of his client.

Business Overhead Expense

A disability income policy which indemnifies the business for certain overhead expenses incurred when the business owner is totally disabled. (H)

Calendar Year

January 1 through December 31 of the same year. Many deductible amount provisions are on a calendar year basis under major medical plans. Also, benefits under basic hospital surgical and medical plans are usually stated as so much for each calendar year. (H)

Capitation (CAP)

A rate paid, usually monthly, to a health care provider. In return, the provider agrees to deliver the health services agreed upon to any covered person. (H)

Carrier

Usually a commercial insurer contracted by the Department of Health and Human Services to process Part B claims payments. (H)

carrier

insurance company or HMO insuring the health plan.

Carrier Replacement

This refers to a situation where one carrier replaces one or more carriers. (H)

Carry Over Provision

In major medical policies, allowing an insured who has submitted no claims during the year to apply any medical expenses incurred in the last three months of the year toward the new calendar year's deductible. (H)

Case Management

The assessment of a person's long term care needs and the appropriate recommendations for care, monitoring and follow-up as to the extent and quality of services to be provided. (H)

Case Manager

A person, usually an experienced professional, who coordinates the services necessary under the case management approach. (H)

Case Mix

The number of cases requiring different needs and uses of hospital resources. (H)

Catastrophe Policy

This is an older name for Major Medical. See Major Medical. (H)

CCRCs

See Continuing Care Retirement Communities (CCRCs). (H)

Certificate Booklet

the plan agreement. A printed description of the benefits and coverage provisions intended to explain the contractual arrangement between the carrier and the insured group or individual. May also be referred to as a policy booklet

Certificate of Authority (COA)

Issued by the state, it licenses the operation of an HMO (Health Maintenance Organization). (H)

Certificate of Need (CON)

Issued by a governmental body. It certifies that the proposed facility will meet the needs of those for whom it is intended. Such need might involve constructing a new health facility, offering a new or different health service, or acquiring new medical equipment. (H)

Chemical Dependency Services

The services required in the treatment and diagnosis of chemical dependency, alcoholism, and drug dependency. (H)

Chemical Equivalents

Drugs which contain identical amounts of the same ingredients. (H)

Christian Science Organization

A religious organization which is certified by the First Church of Christian Scientists. The organization may also be Medicare certified as a hospital or skilled nursing facility. (H)

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

Part of the Uniformed Services Health Benefits Program which supplements the medical care available for families of active, deceased, and retired military personnel. (H)

claim

a formal request made by an insured person for the benefits provided by a policy.

Closed Access

A situation where covered insureds must select one primary care physician. That physician is the only one allowed to refer the patient to other health care providers within the plan. Also called Closed Panel or Gatekeeper model. (H)

Closed Panel

See Closed Access. (H)

COB

Coordination of Benefits. See Nonduplication of Benefits. (H)

COBRA

See Consolidated Omnibus Budget Reconciliation Act of 1986. (H)

COBRA (Consolidated Omnibus Budget Reconciliation Act)

Federal legislation that requires group health plans to provide health plan members the opportunity to purchase continued coverage in the event their insurance is terminated. Applies only to employer groups with 20 or more employees.

Cognitive Impairment

A deficiency in the ability to think, perceive, treason or remember resulting in loss of the ability to take care of one's daily living needs. (H)

co-insurance

the percentage of covered expenses an insured individual shares with the carrier. (i.e., for an 80/20 plan, the health plan member's co-insurance is 20%.) If applicable, co-insurance applies after the insured pays the deductible and is only required up to the plan's stop loss amount. (see "stop loss.")

Coinsurance Clause

A provision stating that the insured and the insurer will share all losses covered by the policy in a proportion agreed upon in advance, i.e., 80-20 would mean that the insurer would pay 80% and the insured would pay 20% of all losses. See also Percentage Participation. (H)

Commercial Policy

In Health Insurance, this term originally applied to policy forms intended for sale to individuals in commerce, as contrasted with industrial workers. Currently the term is loosely used to mean all policies that do not guarantee renewability. (H)

Community Rating

Under this rating system, the charge for insurance to all insureds depends on the medical and hospital costs in the community or area to be covered. Individual characteristics of the insureds are not considered at all. (H)

Competitive Medical Plan (CMP)

This refers to permission given by the federal government that allows an organization to write a Medicare risk contract. (H)

Composite Rate

One rate for all members of the group regardless of their status as single or members of a family. (H)

Comprehensive Major Medical

A plan of insurance which has a low deductible, high maximum benefits, and a coinsurance feature. It is a combination of basic coverage and major medical coverage which has virtually replaced separate hospital, surgical and medical policies with each having its own deductible requirements. Also see Major Medical Insurance. (H)

Concurrent Review

A case management technique which allows insurers to monitor an insured's hospital stay and to know in advance if there are any changes in the expected period of confinement and the planned release date. (H)

Conditionally Renewable

A contract that provides that the insured may renew it to a stated date or an advanced age, subject to the right of the insurer to decline renewal only under conditions stated in the contract. (H)

Confining

A form of disability or sickness that confines the insured indoors, usually at home or in a hospital. Many policies state that coverage is afforded only if the insured is confined. (H)

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986

Legislation providing for a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued for up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may be continued for up to 36 months in nearly all other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age. (H)

Continuation

Allows terminated employees to continue their group health insurance coverage under certain conditions. (H)

Continuing Care Retirement Communities (CCRCs)

Residential communities set up to provide residents with easy access to health care. (H)

Contract Year

This period runs from the effective date to the expiration date of the contract. (H)

Coordination of Benefits (COB)

See Nonduplication of Benefits. (H)

Coordination of Benefits (COB)

A group policy provision which helps determine the primary carrier in situations where an insured is covered by more than one policy. This provision prevents an insured from receiving claims overpayments. (LI,H)

Copay

This is an arrangement where the covered person pays a specified amount for various services and the health care provider pays the remainder. The covered person usually must pay his or her share when the service is rendered. Similar to coinsurance, except that coinsurance is usually a percentage of certain charges where the co-payment is a dollar amount. (H)

Copay Provision

Often used with major medical policies. The copay provision states what percentage of a claim the company will pay and what percentage the insured will pay. For example, an 80 percent copay provision would provide that the insurer pay 80 percent of claims and the insured pay 20 percent. (H)

co-pay/co-payment

the amount an insured individual must pay toward the cost of a particular benefit. For example, a plan might require a $10 co-pay for each doctor's office visit.

Copayment

See Copay. (H)

Corridor Deductible

A Major Medical deductible that provides for a deductible, or "corridor," after the full payment of basic hospital and medical expenses up to a stated amount. In the event of further expenses, payment is on the basis of participation or coinsurance, such as 80%-20% or 85%-15%, and the deductible is that portion paid by the insured. (H)

Cosmetic Procedures

Procedures which improve the appearance, but are not medically necessary. (H)

Cost Contract

An agreement between a provider and the Health Care Financing Administration to provide health services to covered persons based on reasonable costs for service. (H)

Cost of Living Benefit

An optional disability benefit where the monthly benefit will be increased annually once the insured is on claim for 12 months. (H)

Cost Sharing

A situation where covered persons pay a portion of the health costs such as deductibles, coinsurance, or copayment amounts. (H)

Covered Expenses

Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract. (H)

Covered Person

A person who pays premiums into the contract for the benefits provided and who also meets eligibility requirements. (H)

Credentialing

This involves approving a provider based on certain criteria to provide or participate in a health plan. (H)

credit for prior coverage

any pre-existing condition waiting period met under an employer's prior (qualifying) coverage will be credited to the current plan, if any interruption of coverage between the new and prior plans meets state guidelines.

Credit Health Insurance

A group disability income insurance contract whereby a creditor is protected in the event of the total disability of a debtor. The policy will pay benefits equal to the monthly installment of the debtor. (H)

Custodial Care

Care that is primarily for meeting personal needs such as help in bathing, dressing, eating or taking medicine. It can be provided by someone without professional medical skills or training but must be according to doctor's orders. (H)

Date of Service

The date that the health service was provided. (H)

DBL

See Disability Benefits Law. (H)

Death Spiral

The potentially destructive cycle that may occur in an indemnity plan as a result of increased HMO penetration. The process can occur if indemnity plan rates continuously escalate because healthier and younger employees choose HMOs, leaving less healthy individuals in experience-rated indemnity plans. Employer contribution strategies and HMO pricing techniques may aggravate the problem. (H)

deductible

the dollar amount an insured individual must pay for covered expenses during a calendar year before the plan begins paying co-insurance benefits.

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. (H)

Deferred Compensation Administrator

This refers to a company that provides services under a deferred compensation plan. Services may include administration of self-insured plans, compensation planning, salary surveys, retirement planning, etc. (H)

Delete

This refers to the process of taking an individual off Medicare coverage. (H)

Dental Insurance

A group Health Insurance contract that provides payment for certain enumerated dental services. (H)

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. (H)

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. (LI,H)

dependents

usually the spouse and unmarried children (adopted, step or natural) of an employee.

Designated Mental Health Provider

The organization hired by a health plan to provide mental health and substance abuse services. (H)

Detoxification

The process an individual goes through when withdrawing from alcohol. Usually is done under guidance of medical personnel. (H)

Diagnosis

The process of identifying a disease. (H)

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. (H)

Disability Benefits Law

A state law requiring an employer to provide disability benefits to covered employees for nonoccupational injuries, in contrast to Workers Compensation, which pays for occupational injuries. These laws are currently in effect in New York, New Jersey, Rhode Island, California, and Hawaii. (H)

Disability Buy-Sell

A disability income policy used to fund a disability buy-sell agreement whereby the business interest of a disabled stockholder following the elimination period. The policy's benefits may be paid in a lump sum or in installments. (H)

Disability Income Insurance

A form of health insurance that provides periodic payments to replace income, actually or presumptively lost, when the insured is unable to work as a result of sickness or injury. (H)

Disability Insurance Training Council, Inc

The educational arm of the International Association of Health Underwriters, the Health Insurance agents' professional society. It seeks to encourage agent educational projects by local Health associations, conducts university seminars in advanced Health underwriting areas, and conducts annual seminars for home office executives in sociological social insurance and demographic trends that may affect future application of policy forms and Health Insurance. (H)

Disability, Long-Term

See Long-Term Disability. (H)

Disability, Permanent Partial

See Permanent Partial Disability. (WC,H)

Disability, Permanent Total

See Permanent Total Disability. (WC,H)

Disability, Short-Term

See Short-Term Disability. (H)

Disability, Temporary Partial

See Temporary Partial Disability. (WC,H)

Disability, Temporary Total

See Temporary Total Disability. (WC,H)

Discharge Planning

Determining what the patient's medical needs will be after discharge from a hospital or other inpatient treatment. (H)

Dismemberment

The loss of, or loss of use of, specified members of the body resulting from accidental bodily injury. (H)

Dismemberment Benefit

The benefits payable for various types of dismemberment. See also Accidental Death and Dismemberment and Multiple Indemnity. (H)

Dread (or Specified) Disease Policy

Coverage, usually with a high maximum limit, for all types of medical expenses arising out of diseases named in the contract. Common diseases covered are poliomyelitis, diphtheria, multiple sclerosis, spinal meningitis, and tetanus. Cancer is sometimes covered or may be added with some companies by a rider. (H)

Drug Formulary

A schedule of prescription drugs approved for use which will be covered by the plan and dispensed through participating pharmacies. (H)

Drug Price Review (DPR)

A procedure used to determine drug price maximums. It involves determining wholesale drug prices based on the American Druggist Blue Book. (H)

Drug Utilization Review (DUR)

A method for evaluating or reviewing the use of drugs in order to determine the appropriateness of the drug therapy. (H)

Dual Choice

The federal requirement that employers having 25 or more employees who are within the service area of a federally qualified HMO, who are paying at least minimum wage and offer a health plan to their employees, must offer HMO coverage as well as an indemnity plan. (H)

Duplicate Coverage Inquiry (DCI)

A request to determine whether or not other coverage exists. Used to apply the coordination of benefits provisions where two or more insurance companies are involved. (H)

Duplication of Benefits

A situation where identical or overlapping coverage exists between two or more insurance companies or service organizations. (H)

effective date

the date requested by an employer for insurance coverage to begin.

Elective Benefits

Lump sum payments which the insured may generally choose in lieu of periodic payments for certain injuries, such as fractures and dislocations. (H)

Elective Indemnities

See Elective Benefits. (H)

Eligibility Date

The date that a person is eligible for benefits. (H)

Eligibility Period

(1) The period of time during which potential members of a Group Life or Health program may enroll without providing evidence of insurability. (2) The period of time under a Major Medical policy during which reimbursable expenses may be accrued. (H)

Eligibility Requirements

Requirements imposed for eligibility for coverage, usually in a group insurance or pension plan. (LI,H)

Eligible Dependent

A dependent of an insured person who is eligible for coverage according to the requirements set forth in the contract. (H)

Eligible Employee

An employee who is eligible based on the requirements as indicated in the group contract. (H)

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." (H)

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. (H)

Elimination Period

A loosely used term, sometimes designating the probationary period, but most often designating the waiting period in a Health Insurance policy. See also Probationary Period and Waiting Period. (H)

Emergency

An injury or disease which happens suddenly and requires treatment within 24 hours. (H)

Emergency Accident Benefit

A group medical benefit which reimburses the insured for expenses incurred for emergency treatment of accidents. (H)

Emergi-Center

See Freestanding Emergency Medical Services Center. (H)

Employee Benefit Program

Benefits offered an employee at his place of work by his employer, covering such contingencies as medical expenses, disability, retirement, and death, usually paid for wholly or in part by the employer. These benefits are usually insured. (LI,H)

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. (LI,H)

Employee Contribution

The employee's share of the premium costs. (H)

Employer Contribution

The portion of the cost of a health insurance plan which is borne by the employer. (H)

Encounter

Each time a person meets with a health care provider to receive services, is a separate "encounter." (H)

Encounters Per Member Per Year

The total number of encounters per year divided by the total number of members per year. (H)

Enrollee

An eligible individual who is enrolled in a health plan _ does not include an eligible dependent. (H)

Enrolling Unit

The organization (such as an employer) that contracts for participation in a health insurance plan. (H)

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. (H)

Enrollment Period

The amount of time an employee has to sign up for a contributory health plan. (H)

ERISA

See Employee Retirement Income Security Act. (H,LI)

Evidence of Coverage

See Certificate of Coverage. (H)

Evidence of Insurability

The statement of information needed for the underwriting of an insurance policy. (LI,H)

Examination

The medical examination of an applicant for Life or Health insurance. (LI,H)

Examiner

A physician appointed by the medical director of a Life or Health insurer to examine applicants. (LI,H)

Excluded Period

See Probationary Period. (H)

exclusions

expenses which are not covered under an insurance plan. These are listed in the Certificate Booklet.

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. (H)

Expected Claims

The estimated claims for a person or group for a contract year based usually on actuarial statistics. (H)

Expected Morbidity

The expected incidence of sickness or injury within a given group during a given period of time as shown on a morbidity table. (H)

Expense

A policy's share of the company's operating costs, fees for medical examinations and inspection reports, underwriting, printing costs, commissions, advertising, agency expenses, premium taxes, salaries, rent, etc. Such costs are important in determining dividends and premium rates. (H)

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 professionals as being effective. (H)

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. (H)

Explanation of Benefits (EOB)

a carrier's written response to a claim for benefits. Sometimes accompanied by a benefits check.

Explanation of Medicare Benefits

A notice which is sent to the Medicare patient which provides information designed to explain how the claim is to be paid. (H)

Extended Care Facility

A facility such as a nursing home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Three levels of care may be provided--skilled, intermediate, custodial, or any combination. (H)

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. (H)

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. (H)

Family Dependent

A person entitled to coverage because he or she is: 1. The enrollee's spouse, or 2. A single dependent child of either the enrollee or the enrollee's spouse (including stepchildren or legally adopted children), and 3. A resident of the enrollee's home. (H)

Family Expense Policy

A policy which insures the medical expenses of all members of a family. (H)

FASB

The Financial Accounting Standards Board. (H)

Federal Qualification

Approval of any HMO made by the HCFA after conducting their evaluation of methods of doing business, documents, contracts, facilities, and systems. (H)

Fee Maximum

The maximum amount available to a provider for specific health care services under a contract. (H)

Fee Schedule

A list of maximum fees for providers who are on a fee-for-service basis. (H)

Fee-for-Service Equivalency

The difference between the amount a provider receives from a reimbursement system such as capitation (a flat charge per month, for instance) compared to fee-for-service reimbursement. (H)

Fee-for-Service Reimbursement

A health care system where physicians and other providers receive payment based on their billed charge for each service provided. (H)

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. (H)

Financial Accounting Standards Board (FASB)

A non-governmental group that sets standards for generally accepted accounting principles. (H)

Fiscal Intermediary

A commercial insurer contracted by the Department of Health and Human Services for the purpose of processing and administering Part A Medicare claims. (H)

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. (H)

Flexible Benefit Plan

A type of program where employees can tailor their benefits to meet their own specific needs. (H)

Formulary

See Drug Formulary. (H)

Free-Standing Emergency Medical Service Center

A facility whose primary purpose is the provision of care for emergency medical conditions. Also called emergi-center or urgi-center. (H)

Free-Standing Outpatient Surgical Center

A facility which only provides outpatient surgical services. Also called surgi-center. (H)

Frequency

The number of times a service is provided over a given time period. (H)

Funding Level

The dollar amount required to purchase a particular medical care program. Usually measured by the premium rate for an insured program, or an amount assessed for expected claim loss and related fees under a self-funded program. (H)

Funding Methods

The agreed means by which an employer pays for health coverage. (H) Future Increase Option. An option which allows the insured to increase disability income benefits at predetermined times, specified in the policy, without evidence of insurability. (H)

Gatekeeper Model

Under this model of HMO and PPO organizations, the primary care physician (the gatekeeper) is the initial contact for the patient for medical care and for referrals. This is also called a closed access or closed panel. (H)

Generic Drug

A drug which is exactly the same as a brand name drug and which is allowed to be produced after the brand name drug's patent has expired. It is also called a "generic equivalent." (H)

Generic drug

the chemical equivalent to a "brand name drug." These drugs cost less, and the savings is passed onto health plan members in the form of a lower co-pay.

Generic Equivalence

See Generic Drug. (H)

Grievance Procedure

A procedure which allows a member of a health plan or a provider of benefits to express complaints and seek remedies. (H)

Group

Coverage of a number of individuals under one contract. The most common "group" is employees of the same employer. (H)

Group Certificate

The document provided to each member of a group plan. It shows the benefits provided under the group contract issued to the employer or other insured. (LI,H)***

Group Contract

A contract of insurance made with an employer or other entity that covers a group of persons identified by reference to their relationship to the entity buying the contract. The group contractual arrangement is generally used to cover employees of a common employer, members of a trade association or trusteeship, members of a welfare or employee benefit association, members of a labor union, or members of a professional or other association not formed only for the purpose of obtaining insurance. (LI,H)***

Group Credit Insurance

Insurance on the Life or Health of debtors of a creditor, payable for reduction or extinguishment of the debts in case of the disability or death of the debtor. (LI,H)***

Group Disability Insurance

Coverage provided for a group of individuals for loss of compensation due to accident or sickness. (H)

Group Health Insurance

The same definition as Life Insurance but with the application to Health Insurance coverages. See Group Life Insurance. (H)

group insurance

an insurance contract made with an employer or other entity that covers individuals in the group.

Group Model HMO

A health plan where a group of physicians is reimbursed for services they provide at a negotiated rate. The HMO also contracts with hospitals for the care of the patients of the physicians who belong to the group. (H)

Guaranteed Standard Issue (GSI)