Health Insurance

Learn about respite care in health insurance. Understand how temporary care allows family caregivers to take a break while the patient receives professional care.

An employer-funded trust used in a qualified plan to support post-retirement medical or health-related benefits.

The amount the employer pays toward the cost of an employee benefit or insurance plan.

Housing and care communities that combine housing, medical support, and long-term care in one insurance-relevant living model.

A diagnosis identifies a condition from clinical evidence and is the primary trigger for treatment classification and claims coding.

Learn what a Skilled Nursing Facility (SNF) is, and how it provides therapy and nursing care to patients under Medicare.

Disability insurance pays income replacement benefits when illness or injury prevents you from working, subject to the policy's definition of disability.

The time window during which eligible people may enroll in, change, or sometimes cancel coverage under a plan.

Understand the Non-disabling Injury Rider in disability income policies, which covers medical costs for injuries that do not result in total disability.

Learn about the role of the Pharmacy and Therapeutics Committee (P&T) in health insurance, how it influences prescription drug use, and its importance to health plans.

A health-related condition where care requirements or medical limitations limit an insured person to home or facility care.

Medical costs and services a health plan agrees to pay under its coverage terms.

In insurance, disability means a physical or mental condition that satisfies the policy's definition of impaired ability to work or perform specified activities.

A health-insurance table that shows the plan's listed allowance or benefit for specific surgical procedures.

Elective benefits are optional accident or health benefits that pay a stated amount for listed injuries or events, often as a lump sum instead of open-ended reimbursement.

A consumer-facing insurance disclosure that helps compare policy options before purchase or replacement.

Channeling refers to arrangements where provider referrals or privilege rights are restricted to specific clinical networks.

The process a health plan uses to check whether prescription use is safe, appropriate, and consistent with benefit rules.

An individual who meets the policy's definition of who may be insured under a particular plan.

In health insurance, an encounter is a documented interaction in which a covered person receives services from a healthcare provider.

The employer, association, or other group through which people are enrolled in a group insurance plan.

Discover the essentials of hospital affiliation in health insurance, including how agreements between hospitals and health plans affect the care received by members.

Learn about over-the-counter (OTC) drugs, their definition, and their relevance in general insurance. Find out how OTC drugs impact your insurance policy.

Place of service identifies the care setting used on a health-insurance claim, such as an office, hospital, or outpatient facility.

Learn about the proration of benefits in health insurance, an adjustment made to medical benefits due to duplicate coverage from another policy.

Learn about the terminally ill status in health insurance, including its definition and implications for policyholders and beneficiaries.

Learn about the Utilization and Review Committee in healthcare insurance, which monitors services and supplies provided to Medicare patients to ensure compliance and quality.

The maximum amount of coinsurance cost sharing a policyholder pays in a benefit period.

A dependent care plan defines how an insurance plan helps pay for care or support services related to dependents.

Policy coverage extended to family members who qualify as dependents, with specific eligibility and benefit limits.

Learn about Flexible Spending Accounts (FSAs) in health insurance, pre-tax deductions, and coverage for child care or medical expenses. Understand the benefits and limitations, including the forfeiture rule at year's end.

Learn about utilization management in health insurance, a vital method for assessing the need for various medical services to ensure appropriate care and cost management.

Learn about utilization review in health insurance, a crucial process for controlling medical costs by monitoring the quality, necessity, and appropriateness of healthcare services. Understand how employers and insurance companies utilize this process to ensure optimal care.

Learn the purpose and function of a surgi-center, a facility providing surgical services on an outpatient basis. Find out how it fits within the health insurance landscape.

A calendar year deductible resets each January and applies across the entire coverage year.

Rules that determine payment order when more than one insurance plan can cover the same healthcare expense.

A benefit that can cover debt obligations related to healthcare costs when an insured health event impairs repayment.

The process a health insurer or administrator uses to find out whether a person has other coverage that could affect claim payment.

The waiting time that must pass before benefits begin under a disability, health, or similar insurance policy.

A 24-hour care model coordinates health and workers' compensation benefits so employees are covered for illness and injury without coverage-fragmentation delays.

Basic benefits are the minimum health coverage elements required in a policy package before higher levels of coverage are purchased.

Learn what a Superbill is in health insurance. It lists every service provided by a doctor, aiding in accurate billing and claims.

Discover how hospital alliances work in health insurance, enabling multiple hospitals to share services and reduce costs, helping them stay competitive in the healthcare market.

The time window during which the policy pays specified benefits under its terms.

A cafeteria benefit plan gives employees options among approved benefit choices while keeping tax treatment and plan limits compliant.

The policy rule that states the fixed out-of-pocket amount due at service.

Comprehensive health insurance provides broad medical coverage, usually including hospital, physician, emergency, and other major health expenses subject to plan terms.

A contract period that defines how long a health or benefit agreement remains effective.

A disability-linked adjustment that raises benefits to keep pace with inflation or wage changes.

The part of a health insurance claim that the insured pays through deductibles, co-pays, or coinsurance before and while the insurer pays.

The average amount providers in a local market bill for a specific procedure.

A medically supervised process to treat substance withdrawal, often covered under specific health plan criteria.

Disability benefits law refers to state statutes that require or regulate temporary disability benefits for certain non-work-related illnesses or injuries.

The process of arranging a patient's safe transition out of a hospital or facility, with important implications for health insurance authorization and claim payment.

In accident and health insurance, dismemberment means the loss of a limb, sight, hearing, or another specified body function as defined by the policy.

A life insurance provision that pays an extra benefit, often doubling the death benefit, when death results from a covered accident.

A health insurance regulatory concept requiring certain employers to make a qualified HMO option available alongside another health plan offering.

Duplication of benefits occurs when two or more health plans provide overlapping payment for the same expense beyond what coordination rules are meant to allow.

A spouse, child, or other dependent who meets the plan's rules for coverage under an insured employee or member.

A worker who satisfies a group plan's rules for being offered coverage.

A person enrolled in a health plan and recognized by the plan for coverage administration.

The process of getting an eligible person into an insurance plan so coverage can begin under the plan's rules.

An exclusive provider organization is a managed-care health plan that generally pays only for care from network providers, except for emergencies.

Experimental procedures are treatments or services a health plan considers investigational, unproven, or not medically established enough for routine coverage.

The statement a health insurer sends showing how a claim was processed and what amount, if any, the patient may owe.

A health insurance provision that continues certain covered benefits after coverage would otherwise end, usually for members already hospitalized or disabled.

Health coverage issued to an employer or other eligible group sponsor for the benefit of covered members under a group contract.

Learn about the Health Care Financing Administration, a division in the Department of Health and Human Services that oversees Medicare and Medicaid and sets certification guidelines for medical care providers.

Hospital indemnity insurance pays a fixed cash benefit for a covered hospital stay, regardless of the hospital's actual charges.

Mandated benefits are coverages that an insurance policy or health plan must include because a law or regulator requires them.

A tax-based income measure used to determine eligibility or pricing for some insurance and benefits programs.

Explore the crucial role of a Registered Nurse (Health Insurance) in providing nursing care, including medication distribution, and their importance in the healthcare system.

Learn about Retrospective Rate Derivation in Health Insurance, where employers pay a fraction of health care costs and may receive refunds based on actual expenses.

Short-term disability (STD) insurance replaces part of your income for a limited period when illness or injury prevents you from working.

Learn about the Fee for Service (FFS) reimbursement model in health insurance, where health care professionals are paid based on individual services provided.

Learn about Medical Savings Accounts (MSAs) in health insurance, which are funded by employer contributions. Discover how employees can use these accounts for medical expenses and potential cash withdrawals.

Learn about providers in health insurance, including doctors, nurses, and groups who offer medical care and services.

Explore what service benefits in health insurance mean, how they differ from traditional insurance plans, and the advantages they offer based on days of coverage.

Learn about Social Security Tax in Health Insurance, including how it functions, who pays it, and its role in funding social security programs.

Discover how the Prospective Payment System (PPS) operates in health insurance, particularly with Part A Medicare, and how reimbursement is determined based on patient condition at hospital admission.

A statutory wage-replacement benefit for non-work-related disability, sometimes administered through an unemployment insurance system.

Ancillary benefits are secondary benefits in a policy, such as imaging, supplies, or therapy support.

A medical report used in health and life underwriting to verify condition history and treatment details.

A minimum health benefits package focused on essential inpatient and emergency treatment services.

Events or conditions that must occur before a policy begins paying benefits.

A single contract that covers many people in a class under one set of terms.

A fixed amount paid by the insured for certain medical services before insurance covers the remaining part.

Supplemental health coverage designed to help pay deductibles, coinsurance, and other costs not fully paid by Medicare.

The process insurers use to verify and authorize providers or partners before they participate in a health plan.

A program status that allows dependents to receive survivor coverage based on recent covered employment history.

Custodial care refers to non-medical daily living support paid under a care plan or policy benefit terms.

A health policy design approach that adds or removes benefits to match an individual or group risk profile.

An insurance or reimbursement structure that defines what dental services are covered, at what cost, and through which providers.

A dental plan organization coordinates dental-provider networks, claims processing, and benefit rules for dental coverage.

An approved provider through which a plan channels mental health care and reimbursement.

The amount payable under an insurance policy when the insured meets the contract's definition of disability.

Disability income insurance replaces part of an insured person's earnings when sickness or injury prevents them from working.

The health plan's list of covered prescription drugs and the rules that control how those drugs are paid for.

The process a health insurer or plan uses to evaluate prescription pricing and set what it will reimburse under the pharmacy benefit.

The time window a plan uses to determine when a person may enroll in or qualify for coverage under group insurance.