|
Major Hospitalization Policy: The same as Major Medical Insurance, except that it applies to expenses incurred only when the insured is hospitalized.
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 of 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 Health Care Plan: A plan which involves financing, managing, and delivery of health care services. Generally, it involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost effective, but quality, service.
Mandated Benefits: Benefits required by state or federal law.
Mandated Providers: Types of providers of medical care whose services must be included by state or federal law.
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.
Market Assistance Plan: A plan promulgated by the Department of Insurance to assist buyers to obtain certain types of insurance when they are limited in availability.
Maximum Disability Policy: A form of non cancelable Disability Income Insurance that limits an insurer's liability for any one claim but not the aggregate amount of all claims.
Maximum Out-of-Pocket Costs: The most a member will pay considering co-payments, coinsurance, deductibles, etc.
Maturity Date: The date which the policy endows for its total face amount.
Maturity Value: The amount payable under a whole life insurance policy if the insured person lives to the last age on the mortality table on which the values of the contract were based.
Medical Examination: A medical history and exam completed by a doctor that The Insurance Company may require of the applicant during the underwriting process.
Medical Information Bureau (MIB): A service utilized by all life insurance companies who are members of the MIB. Member companies are required to provide brief, coded reports of significant underwriting information to the MIB on a confidential basis. These reports do not include indication as to whether or not an application is issued, rated, or declined. The information is used to protect against the omission of significant underwriting information by forgetful or dishonest applicants. Only member companies have access to this information.
Modified Endowment Contract (MEC): Life insurance policies deemed "investment-oriented" under TAMRA '88. Distributions (loans or surrenders) taken from these policies while the insured is living are taxed as gain-out-first rather than tax basis-out-first. Also, distributions taken before age 59½ are subject to an additional 10% surcharge tax on any gains. Death benefits are treated the same as non-MEC contracts.
Mortality: The frequency of deaths in proportion to a specific population.
Mortality Charge: The cost of the insurance protection (death benefit minus cash value) on a life product. On an illustration, mortality charges referred to as "current" are not guaranteed. Those stated as "maximum" are the contract guarantees. The mortality charge is similar to a one-year term rate and increases with the insured's attained age. Commonly associated with universal life, the mortality charge is multiplied by the net amount-at-risk to determine the cost of providing insurance protection.
Medicaid: A medical benefits program administered by states and subsidized by the federal government. Under this plan, various medical expenses will be paid to those who qualify. It is technically referred to as Title XIX Benefits.
Medical Examination: The examination of an applicant for insurance or a claimant by a physician who acts in the capacity of the insurer's agent.
Medical Examiner: The physician who examines an applicant or claimant on behalf of the insurer and as an agent of the insurer.
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 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.
Medicare: The United States federal government plan for paying certain hospital and medical expenses for persons qualifying under the plan, usually those over 65. The hospital benefits are Part A, and the medical expense portion is Part B. Part A is compulsory social insurance; Part B is voluntary government-subsidized, government-operated insurance.
Medicare Beneficiary: Anyone entitled to Medicare benefits based on the designation by the Social Security Administration.
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 co-payments, and may cover some services and expenses not covered by Medicare.
Member: Anyone covered under a health plan.
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 an 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.
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.
Morbidity: The relative incidence of disease.
Morbidity Rate:The ratio of the incidence of sickness to the number of well persons in a given group of people over a given period of time. It may be the incidence of the number of new cases in the given time or the total number of cases of a given disease or disorder.
Morbidity Table: A table showing the incidence of sickness at specified ages in the same fashion that a mortality table shows the incidence of death at specified ages.
Mortgage Loans: Debt instrument by which the borrower gives the lender a lien on real property as security for the repayment of a loan.
Multi-Disciplinary: Medical treatment which involves care provided by a wide range of specialists.
Mutual Company: An insurance company which is owned by its policy owners, in which the overall net earnings and savings of the company are distributed to the policy owners in the form of dividends. Mutual insurance company policy owners participate in the election of the board of directors. A mutual company has no stockholders. Compare to Stock Company.
National Drug Code (NDC):A system for identifying drugs.
Newspaper Policy: A form of Limited Health Insurance often sold by newspapers to build or conserve circulation.
Noncancellable ("Non-Can"): A contract of Health Insurance 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. The NAIC recommends that the term "noncancellable" not be permitted to be used to designate any form that is not renewable to at least age 50 or for at least five years if issued after age 44. Note that this is in contrast to Guaranteed Renewable, on which the premium may be increased by classes. The premium for noncancellable policies must remain as stated in the policy at the time of issue.
Nonduplication of Benefits: A provision in some Health Insurance policies specifying that benefits will not be paid for amounts reimbursed by others.
Non-Occupational Policy: A policy or provision of a policy which excludes accidents occurring on the job, when such employment is covered by workers compensation.
Nonparticipating Provider: A provider who has not signed a contract with a health plan. A medical or health care provider who is not certified to participate in the Medicare program.
Nonparticipating Provider Indemnity Benefits: Coverage where services provided by nonparticipating providers are reimbursed under an indemnity basis.
Nonprofit Insurers: Insurers organized under special state laws, such as Blue Cross and Blue Shield, who are usually exempt from some taxes imposed on regular insurers, to supply Medical Expense Reimbursement Insurance, usually on a service basis.
Nurse Fees: A provision in a medical expense reimbursement policy calling for reimbursement for the fees of nurses other than those employed by the hospital.
Nursing Home: A licensed health care facility which provides general nursing care to those who are chronically ill or unable to take care of necessary daily living needs. Also known as a Long Term Care facility.
Occupational Classification: In disability insurance, this refers to the applicant/insured's job classification by level of risk. Occupation classifications govern the amount of premium charged, the type of contract, and the range of benefits.
Optional Policy Benefits: The additional policy benefits that are available with various life and health insurance policies. The additional benefits are entirely elective and are subject to approval by underwriting.
Ordinary Life Insurance: Permanent insurance that provides for the payment of proceeds at death or at policy maturity (if the insured is still living at that time). Also known as whole life insurance. Ordinary Life Line: A segment of the insurance industry that includes term, whole life, endowments, universal, and variable life.
Orphan: A policy owner who is not currently being serviced by the writing agent.
Occupational Disease: Impairment of health caused by continued exposure to conditions inherent in a person's occupation or a disease caused by an employment or resulting from the nature of an employment.
Office Visit: Services provided in the physician's office.
Open Access: Allows a participant to see another participating provider of services without a referral from a doctor or gatekeeper.
Open Enrollment Period: A period during which members can elect to come under an alternate plan, usually without providing evidence of insurability.
Optionally Renewable: A contract of Health Insurance in which an insurance company reserves the unrestricted right to terminate coverage at any anniversary or, in some cases, at any premium due date. It may not do so in between.
Outcomes Measurement: A method of keeping track of a patient's treatment and the responses to that treatment.
Out-of-Area: Treatment given to a member outside of the normal area.
Out-of-Pocket Costs: The amounts the covered person must pay out of his or her own pocket. This includes such costs as coinsurance, deductibles, etc.
Out-of-Pocket Limit: The maximum coinsurance an individual will be required to pay, after which the insurer will pay 100% of covered expenses up to the policy limit.
Outpatient: A patient who is not a bed patient in the hospital in which he or she is receiving treatment.
Overage Insurance: Health Insurance issued at ages above the usual limit, which is generally 65.
Overhead Expense Insurance: Insurance which covers such things as rent, utilities, and employee salaries when a business owner becomes disabled. The insurance benefit is generally not a fixed amount, but pays the amount of expenses actually incurred.
Over-The-Counter Drugs (OTC): A drug that can be purchased without a prescription from a doctor.
PAC: See Pre-Authorized Check.
Paid-Up Additions: Paid-up insurance, commonly purchased under a dividend option, but may sometimes be purchased with additional premiums and/or lump sums. Since this insurance is purchased at premium rates based on the insured's original underwriting class, the right to purchase Paid-Up Additions is quite valuable. These additions have cash value as well as a death benefit.
Paid-Up Insurance: Insurance which does not require future premiums to provide the death benefit for the life of the insured person. Limited-pay policies become paid-up after the required number of premiums have been paid. The term may also refer to the end result of a non-forfeiture option that causes a policy to convert to a smaller, but still participating, completely paid-up policy.
Paramedical: A physical examination the insurer may require of applicants during the underwriting process. It is generally not as thorough as a full medical examination. It is usually performed by nurses, rather than doctors.
Partial Disability: In disability insurance, this refers to a situation in which the insured is partially disabled and unable to perform one or more of the principal duties of the job, or unable to spend as much time on the job as before the disability occurred.
Participant: Any employee or former employee who is eligible to receive benefits from an employee benefits plan or whose beneficiaries may be eligible to receive benefits from the plan.
Pension Plan: An employer-sponsored program to provide employees and their spouses with a monthly retirement income payment. Also referred to as a Defined Benefit Plan.
Period Certain: Refers to the payout option on an annuity that will provide a guaranteed installment income for a specific number of years, e.g. 10 years or 20 years. If the annuitant dies during this specified time period, the beneficiary will receive the remaining payments.
Permanent Disability: A disability that will last a lifetime, or at least as far into the future as can be foreseen.
Permanent Life Insurance: Life long, cash value coverage that provides payment of benefits upon death, such as a whole life or endowment contract.
Personal History Interview (PHI): A telephone interview with an applicant or a proposed insured, conducted by a home office employee. In most cases the PHI replaces the need for an inspection report. The purpose of the PHI is to verify information submitted on an application as well as to gain additional knowledge of the applicant's financial condition and social habits.
PHI: See Personal History Interview.
Policy: The written document issued by a life or health insurance company to a policy owner, which expresses the insurance contract between the company and the policy owner.
Policy Date: Specifies when the insurance becomes effective; that is, when the insurer becomes liable to pay benefits provided under the terms of the contract.
Policy Fee: A flat charge for policy administration expenses, usually included in the premium.
Policy Loan: A non-recourse loan from the insurer to the policy owner secured by the policy's cash value. Loan interest, which may be set at a fixed or variable rate, must be paid or accumulated on the loan.
Policy Owner: The individual who owns an insurance policy, and who has all contractual rights. The policy owner is not necessarily the same person as the insured or the payor.
Pool: A method of distributing insurance risk whereby the individual participants share the risk with the other participants.
Portfolio Crediting Method: A method of paying interest or determining dividends which reflects what the company is earning on its overall assets, both old and new. When interest rates are declining the portfolio method tends to illustrate (not guarantee) more favorable results. Likewise, when interest rates are rising, the new money method illustrates more favorable results than the portfolio crediting method. Over the long run, new money and portfolio products backed by similar investments will produce similar results.
Pre-Authorized Check (PAC): A signed form allowing the Insurance Company to withdraw premium payment through an Electronic Funds Transfer from the payor's checking account. See Electronic Funds Transfer.
Premium: The amount set by contract to be paid to the insurance company for benefits provided under the contract.
Presumptive Total Disability: In disability insurance, presumed total disability because of total and irrecoverable loss of sight, hearing, speech, or use of both hands or feet, even if the insured can still work and regular care by a doctor is not required. Under certain Disability Policies, benefits are payable from the date of disability.
Primary Beneficiary: The person who, upon the insured's death, has the first right to receive insurance proceeds.
Proceeds: The net amount of money payable under the terms of a life insurance contract upon the insured's death or upon the maturity of an endowment.
Proposed Insured: The person named in a life insurance application as the person whose life is to be covered by the insurance, if the application is approved
Provision: A statement or clause, found in an insurance policy, to establish some term of the contract.
Paid Business: Insurance for which the application has been signed, the medical examination completed, and the settlement for the premium tendered.
Paid Claims: Amounts paid to providers based on the health plan.
Paid Claims Loss Ratio: Paid claims divided by total premiums.
Partial Disability: A condition in which, as a result of injury or sickness, the insured cannot perform all of the duties of his occupation but can perform some.
Partial Hospitalization Services: Additional services provided to mental health or substance abuse patients which provides outpatient treatment as an alternative or follow-up to inpatient treatment.
Participating Provider: A health care provider approved by Medicare to participate in the program and receive benefit payments directly from carriers or fiscal intermediaries.
Peer Review: Review of health care provided by a medical staff with training equal to the staff which provided the treatment.
Peer Review Organization: Groups of physicians who are paid by the federal government to conduct pre-admission, continued stay and services reviews provided to Medicare patients by Medicare approved hospitals.
Percentage Participation: A provision in a Health Insurance contract which states that the insurer will share losses in an agreed proportion with the insured. An example would be an 80-20 participation where the insurer pays 80% and the insured pays the 20% of losses covered under the contract.
Permanent and Total Disability: Total disability from which the insured does not recover. When used as a definition in a policy "permanent" is presumed after a stated period of time, generally six months.
Permanent Partial Disability: A condition where the injured party's earning capacity is impaired for life, but he is able to work at reduced efficiency.
Permanent Total Disability: A condition where the injured party is not able to work at any gainful employment for the remaining lifetime.
Physical Therapist: A trained medical person who provides rehabilitative services and therapy to help restore bodily functions such as walking, speech, the use of limbs, etc.
Physician Contingency Reserve: A portion of the claim which is deducted and withheld by the health plan before payment is made to the physician. It serves as an incentive for proper quality and utilization of health care. A portion of this reserve may be returned to the physician or to pay claims where the plan needs additional funds. It is also sometimes called "withhold."
Physician's Current Procedural Terminology: This terminology includes medical services and procedures performed by physicians and other providers of health care. The health care industry uses it as a standard for describing services and procedures.
Place of Service: Designates where the actual health services are being performed, whether it be home, hospital, office, clinic, etc.
Point-of-Service Plan: This plan allows a choice of whether to receive services from a participating or nonparticipating provider.
Practical Nurse: A licensed individual who provides custodial type care such as help in walking, bathing, feeding, etc. Practical nurses do not administer medication or perform other medically related services.
Pre-Admission Authorization: A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization and receive authorization for the admission.
Pre-Admission Certification: Before being admitted as an inpatient in a hospital, certain criteria are used to determine whether the inpatient care is necessary.
Preexisting Condition: A physical condition that existed prior to the effective date of a policy. In many Health policies these are not covered until after a stated period of time has elapsed.
Preferred Provider Organization (PPO): An organization of hospitals and physicians who provide, for a set fee, services to insurance company clients. These providers are listed as preferred and the insured may select from any number of hospitals and physicians without being limited as with an HMO. Coverage is 100%, with a minimal co payment for each office visit or hospital stay.
Prescription Medication: A drug which can be dispensed only by prescription and which has been approved by the Food and Drug Administration.
Presumptive Disability: A disability involving loss of sight, hearing, speech, or any two limbs, which is presumed to be a permanent and total disability. In such cases, the insurer does not require the insured to submit to periodic medical examinations to prove continuing disability.
Preventive Care: The type of care best exemplified by routine physical examinations and immunizations, where the emphasis is on preventing illnesses before they occur.
Primary Care: Basic health care provided by doctors who are in the practice of family care, pediatrics, and internal medicine.
Primary Care Network: This is a group of primary care physicians who provide care to those members of a particular health plan.
Primary Care Physician: Some health insurance plans require members to select and seek treatment from a primary physician who either renders treatment or refers the member to an appropriate specialist within the approved health care network.
Primary Coverage: This is the coverage which pays expenses first, without consideration of whether or not there is any other coverage.
Prior Authorization: A cost containment measure which provides full payment of health benefits only when the hospitalization or medical treatment has been approved in advance.
Probationary Period: A period of time between the effective date of a Health Insurance policy, and the date coverage begins for all or certain physical conditions.
Professional Review Organization: An organization of physicians which reviews services to determine if they are medically necessary.
Pro ration of Benefits: The adjustment of Health Insurance policy benefits by reason of the existence of other insurance covering the same contingency.
Prospective Payment System: A system of Medicare reimbursement for Part A benefits which bases most hospital payments on the patient's diagnosis at the time of hospital admission.
Prospective Reserve: A Life or Health Insurance reserve which it is estimated will be sufficient to pay future claims when probable future premiums, interest, and survivorship benefits are added to it.
Prospective Reimbursement: A system where hospitals or other health care providers are paid annually according to rate of payment which has been established ahead of time.
Provider: Any individual or group of individuals that provide a health care service such as physicians and hospitals
Qualified Medicare Beneficiary: This is a person whose income is below the federal poverty guidelines. In these cases, the state is required to pay the Medicare Part B premiums, plus any deductibles or co-payments.
Quality Assurance: Activities involving a review of quality of services and the taking of any corrective actions to remove any deficiencies in the services.
Qualified Benefit/Retirement Plan: A retirement plan that meets certain federal tax requirements and is initiated by a business organization. Money paid by employees of an organization toward such a plan is not taxable as income to the employee and is tax-deductible for the employer.
|
