Sunday, 22 July 2012


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 or allowable charges.

 Eligibility Date
The date that a person is eligible for benefits.

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. Sometimes called “Open Enrollment.” (2) The period of time under a Major Medical policy during which reimbursable expenses may be accrued.

Employee Retirement Income Security Act of 1974 (ERISA)
Federal law governing administration of employee benefit plans and the rights of beneficiaries of the plans. These include the right to receive information on benefits and disposition of claims for benefit appeal rights. ERISA preempts all state laws relating to such plans except those regulating the business of insurance.

Each occasion on which a person meets with a health care provider to receive services.

Encounters Per Member Per Year
The total number of encounters per year divided by the total number of members per year.

An eligible individual who is enrolled in a health plan.

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.

Episode of Care
Treatment rendered in a defined time frame for a specific disease. Episodes provide a useful basis for analyzing quality, cost, and utilization patterns.

Evidence of Insurability
The statement of information needed for the underwriting of an insurance policy. This could be an application containing health questions or an Attending Physicians Statement (APS).

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.

Expected Claims
The estimated claims for a person or group for a contract year based usually on actuarial statistics.

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.

 Experience Rating
The process of setting rates based partially or in whole on previous claims experience and projected required revenues for a future policy year for a specific group or pool of groups.

Experimental or Investigational Procedures
Any health care services, supplies, procedures, therapies, or devices that the health plan determines to be either (1) not proven by scientific evidence to be effective, or (2) not accepted by health care professionals as being effective.

Explanation of Benefits (EOB)
The statement sent to a participant in a health plan listing services, amounts paid by the plan, and total amount owed by the patient.

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.

Extended Coverage
A provision in health policies 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. Sometimes referred to as “continuation of care” or “continuity of care.”

Extension of Benefits
A provision in the insurance policy which allows coverage to continue beyond the expiration date of the policy in the case of insureds who are hospital confined on that date.

The Financial Accounting Standards Board, which is a nongovernmental group that sets standards for generally accepted accounting principles (GAAP).

Family and Medical Leave Act (FMLA)
A federal law passed in 1993 that requires companies to provide eligible workers with up to 12 weeks of job-protected unpaid leave each year for certain medical and family situations, such as the birth of a child or the care of an aged parent. Employees are eligible to take FMLA leave if they’ve worked for the employer for at least 12 months, have worked for at least 1,250 hours over the previous 12 months, and work at a location where the employer has at least 50 workers within 75 miles.

Fee-for-Service (FFS)
The traditional health insurance reimbursement method in which a set fee (e.g., reasonable and customary or allowable charge) is established for each health care service performed. Services are paid for as rendered.

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.

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. Blue Cross Blue Shield of Mississippi is the Fiscal Intermediary for Medicare Part A claims incurred in Louisiana.

Flexible Spending Account
A spending arrangement that allows employers and employees to use pretax dollars to pay for certain health care or dependent care expenses not otherwise covered by insurance. Health care FSAs can be used to finance health care expenses, including deductibles and copayments.

A listing of prescription medications that are preferred for use by the health plan and that will be dispensed through participating pharmacies to covered persons. This list is subject to periodic review and modification by the health plan. A plan that has adopted an “open or voluntary” formulary allows coverage for both formulary and nonformulary medications. A plan that has adopted a “closed, select, or mandatory” formulary limits coverage to those drugs in the formulary.

Franchise Insurance
A plan for covering groups of persons with individual policies having uniform provisions, although they may differ in coinsurance and deductible levels. The individual policies are issued to each person with individual underwriting. Solicitation usually takes place among an employer’s work force with his consent. Premiums are payroll deducted. No employer premium contributions are allowed. LHSIC uses the term “list bill” for this type of plan.

Gatekeeper Model
Under this model a 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. Gatekeepers are typical in HMOs, EPOs, and the in-network portion of a POS.

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.”

Grievance Procedure
A procedure which allows a member of a health plan or a provider of benefits to express complaints and seek remedies.

Coverage of a number of individuals under one contract. The most common “group” is employees of the same employer.

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 association. This is called an “Evidence of Coverage” in HMOs.

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, 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.

Guaranty Fund
See Louisiana Life and Health Insurance Guaranty Association (LLHIGA).

Guaranteed Issue
Required issuance of an insurance policy without any medical underwriting. Under group insurance, all group participants are covered regardless of health history. Guaranteed issue is required under HIPAA for groups under 51. There is no guaranteed issuance of individual policies under state or federal law, except for persons losing group coverage. (See “Conversion”)

Guaranteed Renewability
A right to continue a contract of insurance in force by payment of premiums. The insurer has no right to make any change in any provision of the contract except, in the case of group contracts, on the anniversary date of the contract, and except, in the case of individual contracts, changes made to the contracts of all policyholders uniformly.

HCFA 1500
A form developed by HCFA and used by providers of health services to bill their fees to health carriers.

Health Care Financing Administration (HCFA)
Part of the Department of Health and Human Services, responsible for administration of the Medicare and Medicaid programs.

Health Insurance (HI)
Insurance against loss by sickness or bodily injury. The generic form for those forms of insurance that provide lump sum or periodic payments in the event of loss occasioned by bodily injury, sickness or disease, and medical expense. The term Health Insurance is now used to replace such terms as Accident Insurance, Sickness Insurance, Medical Expense Insurance, Accidental Death Insurance, and Dismemberment Insurance. The form is sometimes called Accident and Health, Accident and Sickness, Accident, or Disability Income Insurance. Dental insurance, disability insurance, and accidental death and dismemberment insurance is also considered health insurance.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)
A federal law designed to provide portability of health coverage by limiting what may be considered pre-existing conditions and exclusions for pre-existing conditions in health plans. HIPAA also requires guaranteed issuance of coverage in the small group market, guaranteed issuance of individual coverage upon loss of group coverage, and guaranteed renewability of coverage in the group and individual markets. Under its Administrative Simplification provisions, HIPAA requires use of unique identifiers, standard data sets, and ensures privacy and security of an individual’s identifiable health information.

A legislatively created insurance pool providing coverage to individuals losing group health coverage. Funded by assessments of health insurers. See Louisiana Health Plan and Conversion.

Health Insurance Purchasing Cooperatives (HIPCS)
Purchasing agents for health insurance consumers under a managed-competition system, also called health insurance purchasing groups, health plan purchasing cooperatives, and health insurance purchasing corporations.

Health Maintenance Organization (HMO)
An HMO is a prepaid medical service plan that provides services to plan members either through employed staff or medical providers who contract with the HMO. Members must use contracted providers to receive benefits except in certain circumstances, such as emergencies.

Collectives of small businesses joined together to purchase health insurance.

Health Plan Employer Data and Information Set (HEDIS)
Standard performance measures collected by the National Committee for Quality Assurance and published in the form of a report card to help employers evaluate plan performance.

High Risk Pool
A legislatively established health plan for uninsurable Louisiana residents. Funded by service charges of $2.00/day for inpatient stays and $1.00 for ambulatory surgical care admissions. Louisiana insurers are required to cover these charges.

Home Health Care
Care received at home as part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services of home health aides or help from homemakers or choreworkers.

An organization which is primarily designed to provide pain relief, symptom management and supportive services for the terminally ill and their families.

Hospital Income or Indemnity Insurance
A form of insurance that provides a stated weekly or monthly payment while the insured is hospitalized, regardless of expenses incurred and regardless of whether or not other  insurance is in force. The insured can use the weekly or monthly benefit as he chooses, for hospital or other expenses. LHSIC sells a form of this insurance called the “Variable Income Plan” or “VIP policy,” which pays a per diem.

In-Area Services
Services which are provided within the “authorized” service area as designated in the plan.

Incurred but Not Reported (IBNR)
Costs associated with a medical services that has been provided, but for which a claim has not yet been received by the insurer. IBNR reserves are recorded by the insurer to account for estimated liability, based on studies of prior lags in claim submissions.

Incurred Claims
The actual insurer liability for a special period, including all claims with dates of service within a specified period (usually called the experience period). Given the time lag between dates of service and the dates of claims payments, adjustments must be made to any paid claims data to determine incurred claims.

A health care insurance plan that reimburses policyholders for covered services. There is usually a deductible which must be met before payment starts and a maximum benefit, either annual or lifetime, that the insurer will pay.

Individual Contract
A contract made with an individual that covers that individual and perhaps also specified members of his family for benefits as described in the policy.

Individual Practice Association (IPA) Model HMO
A situation where an individual practice association is contracted with to provide health care services. The individual practice association contracts with individual physicians or groups of physicians for their services.

Inflation Factor
A premium loading to provide for future increases in medical costs and loss payments resulting from inflation.

In-Force Business
Life or Health Insurance for which premiums are being paid or for which premiums have been fully paid. The term refers to the total face amount of a Life insurer’s portfolio of business. In Health Insurance it refers to the total premium volume of an insurer’s portfolio of business.

Inside Limits
Limits placed on benefits which modify benefits from the overall maximums listed in the policy. An inside limit when applied to room and board, limits the benefit to not only a maximum amount payable, but also limits the number of days the benefit will be paid. A prescription drug inside limit limits the benefit to a specific dollar amount in benefits that will be paid in a particular time period.

Intermediate Care
A level of care associated with a skilled nursing facility which provides nursing care under the supervision of physicians or a registered nurse. The care provided is a step down from the degree of care described as skilled nursing care.

Large Claim Pooling
A technique that helps stabilize premium fluctuations. Large claims (those over a stated amount, sometimes called “shock claims”) are charged to a pool contributed to by many small groups. The pooling level depends on the number of groups in the pool.

Legend Drug
A drug which has on its label “caution: federal law prohibits dispensing without a prescription.”

Length of Stay (LOS)
The total number of days a participant stays in a facility such as a hospital.

Long Term Care (LTC)
Care which is provided for persons with chronic diseases or disabilities. The term includes a wide range of health and social services provided under the supervision of medical professionals.

Long-Term Disability Insurance
A group or individual policy which provides coverage for longer than a short term, often until the insured reaches age 65 in the case of illness and for the remainder of his lifetime in the case of accident. See also Short-Term Disability Insurance.

Loss-Of-Income Benefits
Benefits paid for inability to work for remuneration because of disability resulting from accidental bodily injury or sickness. The loss of income may be real or presumptive.

Louisiana Health Plan
A legislatively created plan consisting of the High Risk Pool, the HIPAA Pool, and a non-operating small employer insurance account.

Louisiana Life and Health Insurance Guaranty Association (LLHIGA)
A legislatively created guaranty association created to cover claims of persons whose insurers are significantly financially impaired or insolvent. Does not cover HMOs. Funded by assessments on insurers. See Guaranty Fund.

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

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

Managed Care Organization (MCO)
Health care plan that emphasizes cost-efficiency in providing care to enrolled members through an organized provider network.

Managed Health Care Plan
A plan which involves financing, managing, and delivery of health care services. Typically, 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.

Maximum Allowable Cost (MAC)
A pricing of generic drugs developed due to the wide variation of different manufacturer costs for identical generic drugs. The MAC is the highest amount that will be paid for the drug regardless of its actual cost.

Medical Expense Trend
The rate at which medical costs are increasing or decreasing, influenced by, for example, utilization, new technology, and billed charges.

Medical Loss Ratio (MLR)
The cost ratio of health benefits used, compared with revenue received. The MLR is calculated as follows: total medical expenses divided by premium revenue.

Medical Savings Accounts (MSA) (also called Medical IRAs and Medisave Accounts)
A health care financing arrangement that allows regular, pre-tax deposits to personal medical accounts that can be used to pay for medical expenditures or health insurance premiums. These accounts work in conjunction with high deductible health insurance policies.

Medical Necessity Review Organization (MNRO)
An organization of physicians that reviews services to determine if they are medically necessary. Louisiana law was enacted in 1999 regulating MNROs and providing immunity from liability if a licensed MNRO is used to review plan medical necessity determinations.

Medically Necessary

Services, treatments, procedures, etc., required to identify or treat a member’s illness or injury, that are consistent with the member’s symptoms or diagnosis and treatment and the most appropriate supply or level of care which can safely be provided to the member.

Medicare Part A
The component of Medicare benefits covering inpatient hospital stays, skilled nursing facilities, home health services and hospice care. Medicare Part A is premium-free for anyone automatically eligible for Medicare. Those not automatically eligible may purchase Medicare Part A coverage for a monthly premium.

Medicare Part B
The optional part of Medicare that can be purchased for a monthly premium. Part B covers outpatient costs, such as the cost of physician services, outpatient hospital services, medical equipment, and medical supplies.

Medicare Supplement Insurance
Private insurance coverage sold on an individual or group basis which helps to fill the gaps in the protection provided by the Medicare program. Medicare supplements cannot duplicate any benefits provided by Medicare, but may pay part or all of Medicare’s deductibles and copayments, and may cover some services and expenses not covered by Medicare.
Medicare+Choice (Also known as Medicare Part C)Medicare+Choice is an expansion of Medicare health plan choices created as part of the Balanced Budget Act of 1997 providing an HMO option.

Medicare Select
A type of Medicare supplemental health insurance policy that requires policyholders to use specific hospitals, and in some cases specific doctors, except in an emergency, in order to be eligible for full benefits.

Member Month
The total number of participants who are members for each month.

Member Touchpoint Measures (MTM)
Refers to the methodology being implemented by the Association to define how well the various plans perform in relationship to the brand identification by their market area. This performance is measured by a series of customer surveys and the utilization of specified metrics reported in the NMIS method.

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

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. 

Multiple Employer Trust (MET) 
A trust consisting of multiple small employers in the same industry, which is formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than would be available to the employers individually. LHSIC uses the term “MET” to describe groups ranging in size from 2-19, even though the trust itself has been dissolved. 

Multiple Employer Welfare Arrangements 
Employer funds and trusts providing health care benefits to individuals. 

Multiple Option Plan 
Under this plan, employees can optionally choose from an HMO, POS, a PPO or a traditional major medical plan. 

National Committee for Quality Assurance (NCQA)
A nonprofit, Washington, D.C.-based organization, the NCQA is dedicated to assessing, measuring, and reporting on the quality of care provided by the national’s managed care plans. The NCQA manages the evolution of the Health Plan Employer Data and Information Set (HEDIS), a managed care performance measurement tool, issuing accreditation in six categories: quality improvement, physician credentials, members’ rights and responsibilities, preventive health services, utilization management, and medical costs. 

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

National Management Information System (NMIS)
Refers to the methodology of the various BCBS plans reporting upon defined standardized metrics relating to business functions performed by the plans. These various plan reports are accumulated and reported by the Association in a quarterly format with the metrics used to rank the plans by peer group and as a member of the whole of the Association 

Nonparticipating Provider 
(1) A provider who has not signed a contract with a health plan. (2) A medical or health care provider who is not certified to participate in the Medicare program. 

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. 

Open Access 
Allows a participant to see another participating provider of services without a referral. Also called open panel. 

Outcomes Measurement 
Assessments that gauge the effect or results of treatment for a particular disease or condition. Outcome measures include the patient’s perception of restoration of function, quality of life, and functional status, as well as objective measures of mortality, morbidity, and health status. 
One who does not fall within the norm. A provider who uses either too many or too few services (for example, anyone whose utilization differs by two standard deviations from the mean on a bell curve is called an outlier.) 

Out-of-Area (OOA)Treatment given to a member outside of his service area. 
Out-of-Pocket Limit 
The maximum dollar amount of coinsurance and deductible an individual will be required to pay, after which the insurer will pay 100% of covered expenses up to the policy limit. 


Post a Comment