Health Insurance Definitions

Premium - Agreed upon fees paid for coverage of medical benefits for a defined benefit period.  Premiums can be paid by employers, unions, employees, or shared by both the insured individual and the plan sponsor.

Copayment - A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. The insurer is responsible for the rest of the reimbursement. There may be separate copayments for different services. Some plans require that a deductible first be met for some specific services before a copayment applies.
 
Deductible - A fixed dollar amount during the benefit period - usually a year - that an insured person pays before the insurer starts to make payments for covered medical services.  Plans may have both per individual and family deductibles. Some plans may have separate deductibles for specific services.  For example, a plan may have a hospitalization deductible per admission. Deductibles may differ if services are received from an approved provider or if received from providers not on the approved list.
 
Coinsurance - A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.
  • Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits up to allowed charges: the individual could also be responsible for any charges in excess of what the insurer determines to be “usual, customary and reasonable”.
  • Coinsurance rates may differ if services are received from an approved provider (i.e., a provider with whom the insurer has a contract or an agreement specifying payment levels and other contract requirements) or if received by providers not on the approved list.
  • In addition to overall coinsurance rates, rates may also differ for different types of services.
 
Maximum out-of-pocket expense - The maximum dollar amount a group member is required to pay out of pocket during a year.  Until this maximum is met, the plan and group member shares in the cost of covered expenses.  After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum. (See previous definition.)  Typically, benefits or cash must be used within the given benefit year or the employee loses the money.  Flexible spending accounts can also be provided to cover childcare expenses, but those accounts must be established separately from medical FSAs.
 
Fully insured plan - A plan where the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs.
 
Minimum premium plan (MPP) – A plan where the employer and the insurer agree that the employer will be responsible for paying all claims up to an agreed-upon aggregate level, with the insurer responsible for the excess.  The insurer usually is also responsible for processing claims and administrative services.
 
Managed care plans - Managed care plans generally provide comprehensive health services to their members, and offer financial incentives for patients to use the providers who belong to the plan.  Examples of managed care plans include: Health maintenance organizations (HMOs), Preferred provider organizations (PPOs), Exclusive provider organizations (EPOs), and Point of service plans (POSs).
 
Managed care provisions - Features within health plans that provide insurers with a way to manage the cost, use and quality of health care services received by group members. Examples of managed care provisions include:
 
  • Preadmission certification - An authorization for hospital admission given by a health care provider to a group member prior to their hospitalization.  Failure to obtain a preadmission certification in non-emergency situations reduces or eliminates the health care provider’s obligation to pay for services rendered. 
  • Utilization review - The process of reviewing the appropriateness and quality of care provided to patients.  Utilization review may take place before, during, or after the services are rendered.
  • Preadmission testing - A requirement designed to encourage patients to obtain necessary diagnostic services on an outpatient basis prior to non-emergency hospital admission.  The testing is designed to reduce the length of a hospital stay.
 
Self-insured plan – A plan offered by employers who directly assume the major cost of health insurance for their employees.  Some self-insured plans bear the entire risk.  Other self-insured employers insure against large claims by purchasing stop-loss coverage. Some self-insured employers contract with insurance carriers or third party administrators for claims processing and other administrative services; other self-insured plans are self- administered.  Minimum Premium Plans (MPP) are included in the self-insured health plan category.  All types of plans (Conventional Indemnity, PPO, EPO, HMO, POS, and PHOs) can be financed on a self-insured basis.  Employers may offer both self-insured and fully insured plans to their employees.
 
  • Reinsurance – The acceptance by one or more insurers, called reinsurers or assuming companies, of a portion of the risk underwritten by another insurer that has contracted with an employer for the entire coverage.
     
  • Stop-loss coverage – A form of reinsurance for self-insured employers that limits the amount the employers will have to pay for each person’s health care (individual limit) or for the total expenses of the employer (group limit).
     
  • ASO (Administrative Services Only) – An arrangement in which an employer hires a third party to deliver administrative services to the employer such as claims processing and billing; the employer bears the risk for claims.  This is common in self-insured health care plans. 
     
  • Third party administrator (TPA) – An individual or firm hired by an employer to handle claims processing, pay providers, and manage other functions related to the operation of health insurance.  The TPA is not the policyholder or the insurer.
 
Health Care Plans and Systems
 
  • Indemnity plan - A type of medical plan that reimburses the patient and/or provider as expenses are incurred.
     
  • Conventional indemnity plan - An indemnity that allows the participant the choice of any provider without effect on reimbursement.  These plans reimburse the patient and/or provider as expenses are incurred.
     
  • Preferred provider organization (PPO) plan - An indemnity plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). The enrollees may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or non- discounted charges from the providers.
     
  • Exclusive provider organization (EPO) plan - A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation.
     
  • Health maintenance organization (HMO) - A health care system that assumes both the financial risks associated with providing comprehensive medical services (insurance and service risk) and the responsibility for health care delivery in a particular geographic area to HMO members, usually in return for a fixed, prepaid fee.  Financial risk may be shared with the providers participating in the HMO.
     
  • Point-of-service (POS) plan - A POS plan is an "HMO/PPO" hybrid; sometimes referred to as an "open-ended" HMO when offered by an HMO.   POS plans resemble HMOs for in-network services.  Services received outside of the network are usually reimbursed in a manner similar to conventional indemnity plans (e.g., provider reimbursement based on a fee schedule or usual, customary and reasonable charges).
     
  • Physician-hospital organization (PHO) - Alliances between physicians and hospitals to help providers attain market share, improve bargaining power and reduce administrative costs.  These entities sell their services to managed care organizations or directly to employers.
 
Usual, customary, and reasonable (UCR) charges - Conventional indemnity plans operate based on usual, customary, and reasonable (UCR) charges.  UCR charges mean that the charge is the provider’s usual fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the circumstances.  Instead of UCR charges, PPO plans often operate based on a negotiated (fixed) schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount.