Health Insurance

Eligible expenses are the medical charges a health plan recognizes as covered or allowable under the policy.

In health insurance, an emergency is a sudden illness or injury requiring immediate medical attention to avoid serious harm.

An employer-sponsored package of insurance and related benefits such as health, life, disability, or other group coverage.

An employer-sponsored plan that provides benefits such as medical, life, disability, or similar protection to employees or their dependents.

A statement showing how a Medicare claim was processed and what amounts Medicare approved, paid, or left to the beneficiary.

A lender-sponsored policy that pays a borrower's debt (or loan payments) if the borrower dies or becomes disabled, depending on coverage.

Explore the essential details about intermediate care in health insurance, including its definition, benefits, and how it differs from skilled nursing care.

Long-term care is ongoing help with daily living or supervision needs caused by chronic illness, disability, or cognitive impairment.

Explore the concept of recidivism in health insurance, focusing on the frequency with which insured individuals are readmitted to the hospital for inpatient treatment due to the same ailment.

Learn about the Staff Model HMO, a type of Health Maintenance Organization (HMO) where premiums are paid directly to the HMO, which employs physicians who receive salaries and predetermined bonuses.

Learn about the time limit on certain defenses in health insurance, a mandatory provision that limits the insurer's ability to deny claims based on pre-existing conditions. Understand its legal implications and coverage details.

Explore the Hospice care services covered by Medicare Part A, including pain and symptom relief for patients with terminal diseases and support for their families.

Learn about the Point of Service Plan (POS) in health insurance, where patients have the flexibility to choose between participating and non-participating providers.

The usual semi-private hospital room charge benchmark used in coverage calculations, usually based on region and provider data.

Business life and health insurance combines personal risk protection for owners or key employees with workforce support goals.

A policy classification category used in some health and disability programs.

A policy mechanism that sets how insured losses are shared between insurer and policyholder.

Coverage that continues when eligibility and enrollment conditions are met, protecting members through policy transitions.

In insurance, contributory usually describes a group plan where covered employees pay part of the premium.

A provider or payer contract that caps reimbursement at a pre-set reasonable cost.

The date when care was actually provided to the patient.

A deductible carryover credit applies certain late-year eligible claims to the next plan year’s deductible.

Dental insurance covers part of the cost of preventive, basic, and major dental care based on a defined dental benefit schedule.

Diagnosis-related groups (DRGs) are classification groups used for standardized hospital payment and claims processing.

Learn how the Disability Insurance Training Council Inc., a branch of the National Association of Health Underwriters, supports education and administers university and executive seminars.

A health insurance form that pays benefits when the insured is diagnosed with one of the serious illnesses specifically named in the policy.

The date a person first qualifies to enroll in or receive coverage under an insurance plan.

Eligibility requirements are the conditions a person must satisfy before becoming eligible for coverage under an insurance plan.

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

ERISA is the federal law that sets core standards for most private-sector employee benefit plans, including many health, life, and disability arrangements.

The anticipated rate of sickness, disability, or medical utilization in a defined insured group.

A licensed facility that provides ongoing nursing, rehabilitative, or custodial care after acute treatment or for long-term care needs.

The document given to an insured member under a group policy that explains the member's benefits and coverage terms.

In-area services are health care services received within a plan’s service area or network, typically covered at more favorable cost-sharing.

Learn what an Intermediate Care Facility is within the health insurance domain. Discover its role in caring for patients who need nursing care but do not require hospital-level attention or skilled nursing facility services.

Explore the Network Model HMO in health insurance, a model that contracts with multiple physician groups allowing broader healthcare access. Learn how this model works and its benefits.

Learn about Qualified Medicare Beneficiary (QMB), who qualifies for Medicare benefits due to income being under the federal poverty guidelines.

A comprehensive guide to recipients in health insurance, focusing on eligibility criteria and benefits under the Medicaid program.

Explore the fundamentals of major medical insurance, a health insurance policy with a high deductible that covers most medical expenses. Learn about its coverage limits, participation clauses, and benefits.

Learn who qualifies as a Medicare beneficiary according to the Social Security Administration and what it means to be eligible for Medicare benefits.

Learn about Relative Value Unit (RVU) - a vital metric used in health insurance to determine surgical costs and values through multiplication with a conversion factor.

Explore the concept of total disability in health insurance, a condition that prevents the insured from working in any capacity due to injury or medical condition. Learn how it varies across policies.

Explore the concept of utilization in health insurance, defined as the amount of use a health plan receives from a specific group of policyholders. Learn how it's measured and its impact on policy costs.

UB-92 is the standardized institutional claim form format used to bill hospital services, helping health insurers adjudicate claims consistently.

CHAMPUS was the earlier military dependent health program that was replaced by the modern TRICARE structure.

Employer-sponsored or group-based health coverage and disability arrangements sold to businesses and institutions.

A health or accident policy benefit that pays for emergency treatment needed immediately after a covered accident.

A member is a person enrolled in an insurance plan (commonly a health plan) and entitled to benefits under its terms.

Allocated benefits are portions of an insurance payment reserved for specific care categories or expense types.

Learn about the significance of referrals in health insurance, where a primary care physician recommends an insured individual to visit a specialist.

One policy form that applies the same coverage terms to a defined group or a portfolio of insured property.

A broad medical expense coverage form that applies across many members or groups under common eligibility and benefit logic.

A health insurance brand network that began as a hospital service organization model and now licenses plans through a broader healthcare market structure.

A major health benefit brand family best known for provider-network based health plans.