Retirement Planning
Where Can I Put My Money to Save For Retirement?
You'd be wise to consider putting money into several savings and investment
vehicles to maximize your return and to ensure you'll be able to live
comfortably during your retirement. Several plans offer you the benefit
of tax deferral, which means that you don't pay taxes on the interest
or capital gains until you withdraw the money.
Here
are some of the most popular retirement saving options:
Individual Retirement Accounts (IRA's)
IRAs were established by the federal government to encourage people
to save for retirement. Some people can contribute a maximum of $4,000
total per year into one or more investment vehicles, such as stocks,
bonds, mutual funds, annuities or certificates of deposit (CDs), on
a tax-deferred basis. IRA earnings are tax-deferred. Ordinary income
taxes are generally due upon withdrawal. Withdrawals prior to age 59
½ may also be subject to a 10 percent tax penalty. Withdrawals must
begin by age 70 ½, or the individual faces additional penalties.
401(k)
Plans
401(k) plans are one of the best retirement savings opportunities available.
Although set up by the company you work for, you typically choose how
much to contribute (subject to IRS limitations) and in which of several
options the money is invested. You also get the option of moving those
funds to other investments at set times. Your current taxable income
is reduced by the amount you contribute to this plan, so your current
tax burden is reduced. And, your employer may contribute matching funds
as a percentage of your investment.
403(b)
Plans
Similar to the 401(k) plan, the 403(b) plan is a tax-deferred retirement
program that can only be established for employees of public education
systems, hospitals and other eligible, nonprofit organizations. Withdrawals
before age 59 1/2 are more restricted than with other retirement programs.
Keogh
Plans
Keogh plans are tax-deferred retirement savings for people who are self-employed.
Usually, 25 percent of your net income, with a maximum of $30,000 per
year, can be contributed on a tax-deferred basis. Keogh plans are, however,
more complicated to implement. Be sure to get tax advice from a financial
advisor before you set up the plan.
Annuities
Unlike most of the previously mentioned savings and investment vehicles,
contributions to annuities are usually made on an after-tax basis, so
they will not reduce your current taxable income. However, annuity earnings
are tax-deferred for individuals so they warrant consideration when
planning for retirement. Deferred annuities allow you to accumulate
money for retirement on a tax-deferred basis. You put money in, and
over time it earns interest or generates investment gains or losses.
"Deferred" refers to the postponement of steady payments to you. These
payments will start later, usually at retirement. With deferred annuities,
taxes on interest and/or earnings also are postponed until you begin
receiving payments.
Source: Adapted from MetLife
What about risk?
All investments involve some risk. If, for example, you put your money
into a vehicle that guarantees a certain return, you run the risk of
not making a substantially larger amount of money if other financial
vehicles start taking off. On the other hand, if you invest in only
the stock market and it starts falling right before you need the money,
you could lose resources you were depending on.
Glossary
of Terms A
Access
The availability of medical care. The quality of one's access to medical
care is determined by location, transportation options, and the type
of medical care facilities available in the area, etc..
Accident
For health insurance purposes, an accident is an unforeseen, unexpected
and unintended event resulting in bodily injury.
Accumulation Period
The period of time during which an insured person incurs eligible medical
expenses toward the satisfaction of a deductible
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 returns to work.
Actual Charge
The actual dollar amount charged by a physician or other provider for
medical services rendered, as distinguished from the allowable charge.
Actuary
A person professionally trained in the mathematical and statistical
aspects of the insurance industry.
Actuaries
frequently calculate premium rates, reserves and dividends and assist
in estimating the costs and savings of benefit changes.
Acute Care
Medical care administered, frequently in a hospital or by nursing professionals,
for the treatment of a serious injury or illness or during recovery
from surgery. Medical conditions requiring acute care are typically
periodic or temporary in nature, rather than chronic.
Additional Drug Benefit
List Drug Maintenance List-A list of commonly prescribed drugs intended
for patients' ongoing or long-term use.
Administrative Services Only (ASO) Agreement
A business contract under which an insurance company agrees to perform
specific administrative duties for the maintenance of a self-funded
health insurance plan.
Admissions/1,000
A statistic used by health insurance companies describing the number
of hospital admissions for each 1000 persons covered under a health
insurance plan within a given time period.
Admits
Hospital admissions. A term used to describe the number of persons admitted
to a hospital within a given period.
Age Limits
Ages below and above which an insurance company will not accept applications
or renew policies.
Agent
A state-licensed individual or entity representing one or more insurance
companies. An agent solicits and facilitates the sale of insurance contracts
or policies and provides services to the policyholder on behalf of the
insurer. See also, Broker.
Allowable Charge
also referred to as the Allowed Amount, Approved Charge or Maximum Allowable.
See also, Usual, Customary and Reasonable Charge. This is the dollar
amount typically considered payment-in-full by an insurance company
and an associated network of healthcare providers. The Allowable Charge
is typically a discounted rate rather than the actual charge. It may
be helpful to consider an example: You have just visited your doctor
for an earache. The total charge for the visit comes to $100. If the
doctor is a member of your health insurance company's network of providers,
he or she may be required to accept $80 as payment in full for the visit
- this is the Allowable Charge. Your health insurance company will pay
all or a portion of the remaining $80, minus any co-payment or deductible
that you may owe. The remaining $20 is considered provider write-off.
You cannot be billed for this provider write-off. If, however, the doctor
you visit is not a network provider then you may be held responsible
for everything that your health insurance company will not pay, up to
the full charge of $100. This term may also be used within a Medicare
context to refer to the amount that Medicare considers payment in full
for a particular, approved medical service or supply.
Allowable Costs
Charges for healthcare services and supplies for which benefits are
available under your health insurance plan.
Allowed Amount
see Allowable Charge
Alternative Medicine
Any medical practice of form of treatment not generally recognized as
effective by the medical community at large. Alternative medicine may
encompass a broad range of services and practices including acupuncture,
homeopathy, aromatherapy, naturopathy, etc.. Many insurance companies
do not provide coverage for these services.
Ambulatory Care
Medical care rendered on an outpatient basis and which may include diagnosis,
certain forms of treatment, surgery and rehabilitation. See also, Ambulatory
Setting.
Ambulatory Setting
Medical facilities such as surgery centers, clinics and offices in which
healthcare is provided on an outpatient basis.
Ancillary Fee
An extra fee sometimes associated with obtaining prescription drugs
which are not listed on a health insurance plan's formulary of covered
medications.
Ancillary Products
Additional health insurance products (such as vision or dental insurance)
that may be added to a medical insurance plan for an additional fee.
Ancillary Services
Supplemental healthcare services such as laboratory work, x-rays or
physical therapy that are provided in conjunction with medical or hospital
care.
Approved Charge
see Allowable Charge.
Approved Health Care
Facility or Program A medical facility or healthcare program (often
organized through a hospital or clinic) that has been approved by a
health insurance plan to provide specific services for specific conditions.
Attending Physician Statement (APS)
A physician's assessment of a patient's state of health as outlined
in office notes and test results compiled by the physician. An APS may
be requested by an insurance company in lieu of a medical examination
in order to determine the state of a health insurance applicant's health
for underwriting purposes.
Basic Hospital Expense Insurance
see Hospitalization Insurance.
Bed Days/1,000
A statistic used by health insurance companies describing the number
of inpatient hospital days for each 1000 persons covered under a health
insurance plan within a given time period.
Benefit
A general term referring to any service (such as an office visit, laboratory
test, surgical procedure, etc.) or supply (such as prescription drugs,
durable medical equipment, etc.) covered by a health insurance plan
in the normal course of a patient's healthcare.
Benefit Riders
This term may be used to describe ancillary products purchased in conjunction
with a medical insurance plan.
Benefit Year
The annual cycle in which a health insurance plan operates. At the beginning
of your benefit year, the health insurance company may alter plan benefits
and update rates. Some benefit years follow the calendar year, renewing
in January, whereas others may renew in late summer or fall.
Birthday Rule
One method used by health insurance companies to determine which parent's
health insurance coverage will be primary for a dependent child, when
both parents have separate coverage. Typically, the health insurance
plan of the parent whose birthday falls earliest in the year will be
considered primary. For more information, see also, COB.
Board-certified
A board-certified physician is one that has successfully completed an
educational program and evaluation process approved by the American
Board of Medical Specialties, including an examination designed to assess
the knowledge, skills and experience required to provide quality patient
care in a specific specialty.
Broker
Though sometimes used in a sense synonymous with the term agent, a broker
typically works to match applicants with a health insurance company
or plan best matched to their needs. The broker is paid a commission
by the insurance company, but represents the applicant rather than the
insurance company itself.
Business License
A license from a governmental agency authorizing an individual or an
employer to conduct business.
COB (Coordination of Benefits)
This is the process by which a health insurance company determines if
it should be the primary or secondary payer of medical claims for a
patient who has coverage from more than one health insurance policy.
See also, Non-duplication of Benefits.
COBRA (Consolidated Omnibus Budget Reconciliation
Act of 1985)
Federal legislation allowing an employee or an employee's dependents
to maintain group health insurance coverage through an employer's health
insurance plan, at the individual's expense, for up to 18 months in
certain circumstances. COBRA coverage may be extended beyond 18 months
in certain circumstances. COBRA rules typically apply when an employee
loses coverage through loss of employment (except in cases of gross
misconduct) or due to a reduction in work hours. COBRA benefits also
extend to spouses or other dependents in case of divorce or the death
of the employee. Children who are born to, adopted, or placed for adoption
with the covered employee while he or she is on COBRA coverage are also
entitled to coverage. All companies that have averaged at least 20 full-time
employees over the past calendar year must comply with COBRA regulations.
Carrier
Any insurer, managed care organization, or group hospital plan, as defined
by applicable state law.
Carry-over Provision
A provision of some health insurance plans allowing medical expenses
paid for by the member in the last three months of the year to be carried
over and applied toward the next year's deductible.
Case Management
When a member requires a great deal of medical care, the health insurance
company may assign the member to case management. A case manager will
work with the patient's healthcare providers to assist in the management
of the patient's long-term needs, with appropriate recommendations for
care, monitoring and follow-up. A case manager will also help ensure
that the member's health insurance benefits are being properly and fully
utilized and that non-covered services are avoided when possible.
Certificate of Coverage (CoC)
A document given to an insured that describes the benefits, limitations
and exclusions of coverage provided by an insurance company.
Chronic
In healthcare and insurance terminology, a chronic condition is one
that is permanent, recurring or long lasting, as opposed to an acute
condition.
Claim
A bill for medical services rendered, typically submitted to the insurance
company by a healthcare provider.
Coinsurance
The amount that you are obliged to pay for covered medical services
after you've satisfied any co-payment or deductible required by your
health insurance plan. Coinsurance is typically expressed as a percentage
of the charge or allowable charge for a service rendered by a healthcare
provider. For example, if your insurance company covers 80% of the allowable
charge for a specific service, you may be required to cover the remaining
20% as coinsurance.
Co-payment
A specific charge that your health insurance plan may require that you
pay for a specific medical service or supply, also referred to as a
"co-pay." For example, your health insurance plan may require a $15
co-payment for an office visit or brand-name prescription drug, after
which the insurance company often pays the remainder of the charges.
Date of Service
The date on which a healthcare service was provided.
Deductible
A specific dollar amount that your health insurance company may require
that you pay out-of-pocket each year before your health insurance plan
begins to make payments for claims. Not all health insurance plans require
a deductible. As a general rule (though there are many exceptions),
HMO plans typically do not require a deductible, while most Indemnity
and PPO plans do.
Deductible Carry-over Credit
see, Carry-over Provision
Dependent Coverage
Health insurance coverage extended to the spouse and unmarried children
of the primary insured member. Certain age restrictions on the coverage
of children may apply.
Designated Mental Health Provider
An organization hired by a health insurance plan to provide mental health
and/or substance abuse treatment services.
Drug Formulary
A list of prescription medications selected for coverage under a health
insurance plan. Drugs may be included on a drug formulary based upon
their efficacy, safety and cost-effectiveness. Some health insurance
plans may require that patients obtain preauthorization before non-formulary
drugs are covered. Other health insurance plans may require that a patient
pay a greater share or all of the cost involved in obtaining a non-formulary
prescription.
Drug Maintenance List
A list of commonly prescribed drugs intended for patients' ongoing or
long-term use.
Durable Medical Equipment (DME)
Medical equipment used in the course of treatment or home care, including
such items as crutches, knee braces, wheelchairs, hospital beds, prostheses,
etc.. Coverage levels for DME often differ from coverage levels for
office visits and other medical services.
ERISA (Employment Retiree Income Security Act
of 1974)
Federal legislation designed to protect the rights of retirees and beneficiaries
of benefit plans offered by employers.
Effective Date
The date on which health insurance coverage comes into effect.
Eligibility Date
The date on which a person becomes eligible for insurance benefits.
Eligibility Requirements
Conditions that must be met in order for an individual or group to be
considered eligible for insurance coverage.
Eligible Dependent
A dependent (usually spouse or child) of an insured person who is eligible
for insurance coverage.
Eligible Employee
An employee who is eligible for insurance coverage based upon the stipulations
of the group health insurance plan.
Eligible Expenses
Expenses defined by the health insurance plan as eligible for coverage.
Eligible Person
This term is used to designate a person who is eligible for insurance
coverage even though he or she may not be an employee, but rather a
member of an organization or union.
Employee Certificate of Insurance
see Certificate of Coverage.
Employee Contribution
The portion of the health insurance premium paid for by the employee,
usually deducted from wages by the employer.
Employer Contribution
The portion of an employee's health insurance premium paid for by the
employer.
Enrollee
An eligible person or eligible employee who is enrolled in a health
insurance plan. Dependents are not referred to as enrollees.
Enrollment
The process through which an approved applicant is signed up with the
health insurance company and coverage is made effective. This term may
also be used to describe the total number of enrollees in a health insurance
plan.
Enrollment Period
The period of time during which an eligible employee or eligible person
may sign up for a group health insurance plan.
Evidence of Coverage
see Certificate of Coverage.
Evidence of Insurability
When applying for an individual health insurance plan, an applicant
may be asked to confirm his or her health condition in writing, through
a questionnaire or through a medical examination. When applying for
group health insurance, evidence of insurability is only required in
specific cases (for instance, when a person fails to enroll in the group
plan during the enrollment period.
Examination
Exclusions
Specific conditions, services or treatments for which a health insurance
plan will not provide coverage.
Experimental or Investigational Procedures
Explanation of Benefits (EOB)
A statement sent from the health insurance company to a member listing
services that were billed by a healthcare provider, how those charges
were processed, and the total amount of patient responsibility for the
claim.
Extended Coverage
Extension of Benefits
Fee-for-service Plan
Fictitious Business Name Statement
Formulary see Drug Formulary.
Gatekeeper
Generic Drug
A drug which is exactly the same as a brand name prescription drug,
but which can be produced by other manufacturers after the brand name
drug's patent has expired. Generic drugs are usually less expensive
than brand name drugs.
Grace Period
A time period after the payment due date, during which insurance coverage
remains in force and the policyholder may make a payment without penalty.
Grievance Procedure
Group
Group Health Insurance
Guaranteed Issue (GI)
A term used to describe insurance coverage that must be issued regardless
of health status. In most states, group health insurance plans are often
described as guaranteed issue plans, because a health insurance company
generally cannot refuse coverage to a qualifying business or organization
based on the health status of their employees or members. In some states,
all health insurance plans are guaranteed issue.
Guaranteed Renewable Contract
HIPAA (Health Insurance Portability and Accountability Act of 1996)
Legislation mandating specific privacy rules and practices for medical
care providers and health insurance companies, designed to streamline
the healthcare and insurance industries and to protect the privacy and
identity of healthcare consumers. HIPAA also provides additional protections
for consumers, designed to help them obtain or retain health insurance
coverage in certain circumstances. For more information on HIPAA rules
and regulations, visit the Centers for Medicare and Medicaid Services
website at http://www.cms.hhs.gov.
HMO
(Health Maintenance Organization)
A health insurance plan or organization that provides a wide range of
comprehensive healthcare services through a network of doctors, hospitals,
labs, etc. who agree to provide services to HMO members at a pre-negotiated
rate. As a member of an HMO, you will need to see your primary care
physician for care or a referral to a specialist, except in case of
emergency. Your choice of doctors is often restricted to those in the
network. As an HMO member, if you don't use the healthcare providers
that participate in your plan's network, you will usually bear the full
cost of these services.
HSA (Health Savings Account)
Health Care Financing Administration (HCFA)
Health Services Agreement
Home Health Agency
Home Health Care
Hospice Care
Care rendered either on an inpatient basis or in the home setting for
a terminally ill patient. Often referred to as "palliative" or "supportive"
care, hospice care emphasizes the management of pain and discomfort
and the emotional support of the patient and family. See also, Respite
Care.
Hospital Benefits
Hospitalization Insurance
IPA (Individual Practice Association)
An organization of physicians who may maintain separate offices but
who negotiate contracts with insurance companies and medical facilities
as a group. Some health insurance applications will ask you to provide
your primary care physician's IPA number. It can usually be found in
the health insurance plan's online directory.
In-area Services Healthcare services
rendered within a health insurance plan's coverage area.
Incontestable Clause
A provision in an insurance policy that states that the validity of
the insurance contract cannot be contested after two (or sometimes three)
years.
Indemnity Plan
A health insurance plan that reimburses the member or healthcare provider
at a certain percentage of charges for services rendered, often after
a deductible has been satisfied. Indemnity plans typically place no
restrictions on which providers a member may visit for healthcare services.
Indemnity plans are also referred to as "fee-for-service" plans. They
offer great freedom in choosing your healthcare provider, but may involve
more paperwork and out-of-pocket expenses for the member.
Individual and Family Health Insurance
A type of health insurance purchased by an individual or family, independent
of any employer group or organization. In most states, a health insurance
company may decline coverage for an individual or family health insurance
plan based on the medical conditions or health histories of the applicants
or dependents.
Inpatient
A term used to describe a person admitted to a hospital for at least
24 hours. It may also be used to describe the care rendered in a hospital
when the duration of the stay is at least 24 hours.
Integrated Delivery System
Intermediate Care
Lapse
The termination of insurance coverage due to lack of payment after a
specific period of time.
Length of Stay (LOS)
Lifetime Maximum
The maximum dollar amount that a health insurance company agrees to
pay on behalf of a member for covered services during the course of
his or her lifetime.
Limitations
A term referring to any maximums that a health insurance plan imposes
on specific benefits.
Long-term Care
MSA (Medical Savings Account)
Major Medical Insurance
Managed Care
Maximum Allowable
see Allowable Charge.
Maximum Out-of-pocket Costs
The most a member will be required to pay out-of-pocket in a benefit
year, often including co-payments coinsurance and deductibles.
Medicaid
Medical Necessity
A basic criterion used by health insurance companies to determine if
healthcare services should be covered. A medical service is generally
considered to meet the criteria of medical necessity when it is considered
appropriate, consistent with general standards of medical care, consistent
with a patient's diagnosis, and is the least expensive option available
to provide a desired health outcome. Of course, preventive care services
that may be covered under a health insurance plan are not always subject
to the criteria of medical necessity.
Medicare
Medicare Beneficiary
Medicare Supplemental Insurance
Member
Anyone covered under a health insurance plan, an enrollee or eligible
dependent.
National Association of Insurance Commissioners
(NAIC)
National Drug Code (NDC)
A system employed by healthcare providers and insurance companies for
classifying and identifying drugs. Each prescription drug in common
use is assigned an NDC number.
Network Provider
A healthcare provider who has a contractual relationship with a health
insurance company. Among other things, this contractual relationship
may establish standards of care, clinical protocols, and allowable charges
for specific services. In return for entering into this kind of relationship
with an insurance company, a healthcare provider typically gains in
numbers of patients and a primary care physician may receive a capitation
fee for each patient assigned to his or her care.
Non-duplication of Benefits see, COB.
Nursing Home
Open Enrollment
Period A time period during which eligible persons or eligible employees
may opt to sign up for coverage under a group health insurance plan.
During an open enrollment period, applicants typically will not be required
to provide evidence of insurability.
Out-of-network Care
Healthcare rendered to a patient outside of the health insurance company's
network of preferred providers. In many cases, the health insurance
company will not pay for these services.
Out-of-pocket Costs
Healthcare costs that a patient or enrollee must pay for out of his
or her own pocket, often including such costs as coinsurance, deductibles,
etc..
Out-of-pocket Maximum
see Maximum Out-of-pocket Costs.
Outpatient
A term referring to a patient who receives care at a medical facility
but who is not admitted to the facility overnight, or for 24 hours or
less. The term may also refer to the healthcare services that such a
patient receives.
Over-the-counter (OTC) Drugs
Drugs that may be obtained without a prescription.
POS (Point of Service) Plan
A type of managed care health insurance plan. Benefit levels vary depending
on whether you receive your care in or out of the health insurance company's
network of providers. POS plans combine elements of both HMO and PPO
plans. As a member of a POS plan, you will likely be required to designate
a primary care physician who will then make referrals to network specialists
when needed. You may receive care from non-network providers but with
greater out-of-pocket costs. With a POS plan, you may be responsible
for co-payments, coinsurance and an annual deductible.
PPO (Preferred Provider Organization) Plan
A type of managed care health insurance plan that allows you, as a member,
to visit whatever in-network physician or healthcare provider you wish
without first requiring a referral from a primary care physician. Services
will typically be covered at a higher benefit level when rendered by
a network provider. As a member of a PPO plan, you will not be required
to choose a primary care physician, but may self-refer to specialists
of your choice. PPO plans may require co-payments or coinsurance and
almost always require that you pay an annual deductible before coverage
begins.
Part-time Employee
Partial Disability
Partial Hospitalization Services
Participating Provider
Generally, this term is used in a sense synonymous with Network Provider.
However, not all healthcare providers contract with health insurance
companies at the same level. Some providers contracting with insurers
at lower levels may sometimes be referred to as "participating providers"
as opposed to "preferred providers."
Peer Review
Place of Service
Policy Term
Practical Nurse
Pre-admission Authorization
Preauthorization/Precertification
These are terms that are often used interchangeably, but which may also
refer to specific processes in a health insurance or healthcare context.
1) Most commonly, "preauthorization" and "precertification" refer to
the process by which a patient is pre-approved for coverage of a specific
medical procedure or prescription drug. Health insurance companies may
require that patients meet certain criteria before they will extend
coverage for some surgeries or for certain drugs. In order to pre-approve
such a drug or service, the insurance company will generally require
that the patient's doctor submit notes and/or lab results documenting
the patient's condition and treatment history. 2) The term "precertification"
may also be used to the process by which a hospital notifies a health
insurance company of a patient's inpatient admission. This may also
be referred to as "pre-admission authorization."
Pre-existing Condition
A health problem that existed or was treated before the effective date
of your health insurance coverage. Most health insurance contracts have
a pre-existing condition clause that describes conditions under which
the health insurance company will cover medical expenses related to
a pre-existing condition. For more information, see also Pre-existing
Condition Exclusion.
Pre-existing Condition Exclusion
see Pre-existing Condition. In some cases, a health insurance company
may exclude a patient's pre-existing conditions from coverage under
a new health insurance plan. This is more typical with individual and
family health insurance plans and less common with group health insurance
plans. HIPAA legislation imposes certain limitations on when a health
insurance company can exclude coverage for a pre-existing condition.
Premium
The total amount paid to the insurance company for health insurance
coverage. This is typically a monthly charge. Within the context of
group health insurance coverage, the premium is paid in whole or in
part by the employer on behalf of the employee or the employee's dependents.
Prescription Medication Preventive Care
Medical care rendered not for a specific complaint but focused on prevention
and early-detection of disease. This type of care is best exemplified
by routine examinations and immunizations. Some health insurance plans
limit coverage for preventive care services, while others encourage
such services. Note that well-baby care, immunizations, periodic prostate
exams, pap smears and mammograms, though considered preventive care,
may be covered even if your health insurance plan limits coverage for
other preventive care services.
Primary Care
Basic healthcare services, generally rendered by those who practice
family medicine, pediatrics or internal medicine. Primary Care Physician
(PCP) Under an HMO or POS plan, a patient may be required to choose
a primary care physician. A primary care physician usually serves as
a patient's main healthcare provider. The PCP serves as a first point
of contact for healthcare and may refer a patient to specialists for
additional services. See also, Primary Care.
Primary Coverage
If a person is covered under more than one health insurance plan, primary
coverage is the coverage provided by the health insurance plan that
pays on claims first. See also, COB. Prior Authorization see Preauthorization/Precertification
#1.
Probationary Period
A waiting period determined by the health insurance company during which
coverage for certain pre-existing conditions may be excluded.
Provider
A term commonly used by health insurance companies to designate any
healthcare provider, whether a doctor or nurse, a hospital or clinic.
Provider Write-off
The difference between the actual charge and the allowable charge, which
a network provider cannot charge to a patient who belongs to a health
insurance plan that utilizes the provider network. See Allowable Charge
for more information.
Qualifying Event
An event (such as termination or employment, divorce or the death of
the employee) that triggers a group health insurance member's protection
under COBRA. See COBRA for more information.
Rating Process Reasonable and Customary Charge
see Usual, Customary and Reasonable (UCR) Charge.
Referral
The process through which a patient under a managed care health insurance
plan is authorized by his or her primary care physician to a see a specialist
for the diagnosis or treatment of a specific condition.
Registered
Nurse (RN) Renewal
Renewal occurs when a member continues coverage under a health insurance
plan beyond the original time frame of the contract. At the end of each
benefit year, a plan member is generally invited to renew his or her
coverage.
Renewal Date
The date on which a member's health insurance plan benefit year renews.
Respite Care
Rider An amendment or modification to an insurance contract. See also,
Benefit Riders.
Schedule C
Schedule K-1 Second Surgical Opinion Secondary Care Secondary Coverage
When a person is covered under more than one health insurance plan,
this term describes the health insurance plan that provides payment
on claims after the primary coverage. See also Primary Coverage and
COB.
Self-funded Health Insurance Plan
Service Area A health insurance plan that is funded by an employer rather
than through a health insurance company. A health insurance company
will typically handle the administration of such a plan, but the cost
of claims will be paid for by the employer through a fund set up for
this purpose. See also, Administrative Services Only (ASO) Agreement.
Short-term Plans Skilled Nursing Care Specialist
A doctor who does not serve as a primary care physician, but who provides
secondary care, specializing in a specific medical field. See also,
Secondary Care.
Standard Industrial Classification (SIC) Codes
Subrogation Subscriber
This term may be used in two senses: First, it may refer to the person
or organization that pays for health insurance premiums; Secondly, it
may refer to the person whose employment makes him or her eligible for
group health insurance benefits.
Temporary Partial Disability
Temporary Total Disability
Tertiary Care
Terminally Ill
Treatment Facility
Triage
Underwriting
The process by which an insurer determines whether it will accept an
application for insurance based upon risks and projections, and through
which a determination on monthly premium is made.
Uniform Billing Code of 1992 (UB-92)
The Uniform Billing Code of 1992 set industry-wide standards for medical
billing practices.
Usual, Customary and Reasonable (UCR) Charge
This refers to the standard or most common charge for a particular medical
service when rendered in a particular geographic area. It is often employed
in determining Medicare payment amounts.
Utilization
This term refers to how frequently a group uses the benefits associated
with a particular health insurance plan or healthcare program.
Utilization Management/Review Vision Care Coverage
An insurance plan typically offered only on a group basis which covers
routine eye examinations and which may also cover all or part of the
costs associated with contact lenses or eyeglasses.
W-2
The federal tax form used to report an employee's wages and taxes.
Waiver (Exclusion Endorsement)
An agreement under which a member agrees to waive coverage for specific
pre-existing conditions or for specific future conditions.
Waiver of Premium
In some cases, a waiver of premium may be granted, allowing a member
to maintain health insurance coverage in full force without payment.
A waiver of premium is typically only granted in cases of permanent
and total disability.
Well-baby/Well-child Care
Regularly scheduled, preventive care services, including immunizations,
provided to children up to an age specified by a health insurance company
or mandated by a government agency. HMO and POS plans typically provide
coverage for well-baby care, though coverage for these services may
be limited under a PPO plan.
Well-woman Care
care rendered either on an inpatient basis or in the home setting for
a terminally ill patient. Often referred to as "palliative" or "supportive"
care, hospice care emphasizes the management of pain and discomfort
and the emotional support of the patient.
