A professional who mathematically analyzes and determines the price of the risk associated with providing insurance coverage. An actuary may also determine the anticipated cost of providing future benefits. Factors considered in the study include the projection of future claims experience, administrative expenses and anticipated investment return.
A type of contract with an insurance company or a third-party administrator that provides an employer with administrative services. It does not provide coverage for risk or insurance protection. The usual expenses covered include claims processing, plan-design advice and printing benefits booklets. These contracts are usually entered into by large employers who can afford the risk of providing insurance protection with their own money.
A person who is designated to be responsible for the proper operation and administration of a plan. When the plan sponsor does not designate a person for this duty, then ERISA considers the plan sponsor to be plan administrator.
A tendency which occurs when a person makes a decision based on his/her diminished health condition or frequency of needed treatment and is, therefore, considered a poorer claims risk than most others in the group.
Licensed by the state, performs the functions for sole proprietors and small businesses that Human Resource Departments do for large businesses, gathers census data, prepares proposals, makes presentations to businesses, explains benefits to employers, does field underwriting when required, delivers policies and certificates, explains benefits to employees, assists in handling claims, services the business in any other related tasks required by the employer or sole proprietor.
Maximum amount a plan sponsor (employer) is liable for any single loss or series of losses.
For aggregate stop-loss insurance, it is the point at which the stop-loss insurance carrier begins to reimburse the employer based upon the cumulative total of claims paid within a policy year.
For specific stop-loss insurance, it is the point at which the stop-loss insurance carrier begins to reimburse the employer based upon the individual’s total of claims paid within a policy year. The practice of medical care providers (such as doctor, hospital or other medical practitioner) billing the insurer for full costs, then billing the insured for the portion of the bill which was not paid.
The person entitled to receive benefits under a plan, including the covered employee and his or her dependents.
A period of time during which benefits are payable under a plan or insurance contract.
A plan which offers a choice between two or more qualified benefits or a choice between cash and one or more qualified benefits and which complies with Section 125 of the Internal Revenue Code (also known as flexible benefit plans or flex plans).
A form of compensation used primarily by HMOs to pay providers a periodic fee (usually a per member, per month fee) in return for delivering as many necessary health care services as the insured may need.
An insured’s request for reimbursement from an insurance company or plan for covered medical expenses.
Refers to a health care program that requires the insured to use certain providers from a list provided by the plan. The primary care provider is responsible for all health care needs and refers to a specialty physician or hospitalization only when medically needed.
An agreement between the insured and the insurance company where payment is shared for all claims covered by the policy. A typical arrangement is 80%/20% up to $5,000. The insurance company pays 80% of the first $5,000 and the insured pays 20%. Usually after 80% of $5,000, the insurance company then pays 100% of covered expenses during the remainder of the calendar year up to any limits of the policy.
A rating method that determines a single average premium based on the characteristics and claims experience of an entire membership such as an HMO or an insurance pool. Age, lifestyle, industry, health factors and gender are not used to determine rates. (See Adverse Selection)
A contractual right given to an insured person whose group coverage terminates to be able to convert to an individual policy without providing evidence of insurability.
A contractual provision to prevent an insured from receiving duplicate benefits from two or more group plans and profiting from over-insurance.
A small charge paid at the time a medical service is received. It does not accumulate toward a plan’s deductible or out-of-pocket maximum and is designed to discourage utilization.
Efforts or activities designed to reduce or slow down the cost increases of medical care services.
The sharing of costs between the payment of premium costs and medical expenses by the health care plan and its insured through employee contributions, deductible, co-insurance and co-payments.
The increased cost of medical care to other patients to make up for losses incurred in providing care to patients who are under-insured or who have no coverage.
The different types of options selected and the benefits paid under a plan or insurance contract.
An expense which will be reimbursed by the terms of the plan or insurance contract.
The amount that the covered insured must pay before a plan or insurance contract starts to reimburse for eligible expenses.
The Department of Labor, a federal executive department established in 1913 and charged with administering and enforcing statutes that promote the welfare of U.S. wage earners by improving their working conditions and advancing their opportunities for profitable employment.
An arrangement where an employer will offer an alternative in addition to its original health plan.
The portion of the medical care provider’s services that is covered for payment under the terms of the health plan or insurance contract.
A federal law which originally set minimum standards for funding, vesting and termination of employer-sponsored pension plans. ERISA also contains provisions to protect the interests of participants and beneficiaries in welfare plans. Welfare plans must be in written form, describe the benefits, and name the persons responsible for the operation of the plan.
A procedure used to review factors concerning a person’s physical condition and medical history. From this information, the plan or insurance company evaluates whether the risk of the individual will be accepted and if they will offer coverage.
Specific conditions or services that are not covered by the terms of the plan or insurance contract.
A different type of Preferred Provider Organization (PPO) which requires the insured to use only the listed providers or to otherwise forfeit benefit reimbursement altogether.
A dollar amount which represents the expected claims which will be paid during any plan or contract period.
Refers to the history of actual claims paid for the contract period (see Paid Claims) or can refer to the history of claims incurred during a contract period.
The process of using a group's own premium and claims experience to calculate premium rates. If the claims experience for the previous year was favorable, the insurer considers reducing the premium rates for the coming year. If the experience was unfavorable, the insurer attempts to discover the reason and may propose higher premium rates for the next year.
(1) The portion of a group insurance premium that is returned to a group policyholder whose claims experience is better than had been expected when the premium was calculated. Also called a dividend, an experience rating refund, and a retroactive rate reduction. (2) The portion of a reinsurance premium that is returned to the ceding company when claims experience is better than had been expected when the premium was calculated.
A document sent to an insured when a claim is handled by the plan or insurance company. The document explains how reimbursement was made, or why the claim was not paid, and if any additional information is needed. The appeals procedure should be outlined to advise the insured of his/her rights if there is dissatisfaction with the decision.
Benefits that continue, or become payable, after the termination of coverage from a plan or insurance contract. For example, a hospitalization that continues after coverage would normally cease.
An HMO that meets the requirements of the Health Maintenance Organization Act of 1973. Under the law, these HMOs receive advantages, such as eligibility for federal loans.
The traditional reimbursement system where the providers of medical care receive a benefit payment calculated on the basis of their billed charge. Under this arrangement plans or insurers have not established contracted or capitulated rates of payment with providers prior to the insured’s claim occurrence.
Under ERISA, any person or organization that manages or controls money or financial assets belonging to others, or that offers financial advice for a fee.
Refers to those costs which are payable monthly and which do not relate to actual claims paid or incurred (for example, premium and administration costs).
An employer-sponsored benefit that enables participants to use pre-tax dollars to pay for out-of-pocket medical expenses (Health FSA) or child care expenses (Dependent Care FSA). A Dependent Care FSA is also known as a DCAP.
The employer pays the entire premium and, in return, transfers all of the risk and responsibility for claims payment to the insurance company.
A health professional within a managed-care environment who determines the patient’s access to treatment. The primary care physician treats the patient and determines access to further treatment and specialists.
A qualifying question asked by an insurance company at the time of application to help identify risk(s). Example: “Have you ever been treated for a heart attack or heart condition?”
Time period that follows the premium due date when the coverage and policy remain in force.
The applicant is guaranteed coverage up to an agreed amount or level without evidence of insurability (see Evidence of Insurability).
The insured’s right to continue an in-force policy by the timely payment of premiums. The insurance company cannot charge the coverage or refuse to renew the coverage for other than non-payment of premiums (includes health conditions and/or marital or employment status).
Health Alliance or Health Insurance Purchasing Cooperatives (HIPCs) are groups or entities whose primary purpose is to negotiate with health plans to provide coverage at competitive prices to members of the alliance.
HIPAA is a federal law that limits pre-existing condition exclusions, permits special enrollment when certain life or work events occur, prohibits discrimination against employees and dependents based on their health status, and guarantees availability and renewability of health coverage to certain employees and individuals.
Health Maintenance Organization (HMO) An organization that provides a wide range of health services for a fixed, pre-paid premium. The HMO may provide all services or may contract with other sources for additional services. HMOs fall into four categories:
An employer-sponsored benefit that enables participants to pay for out-of-pocket medical expenses from an account that is completely funded by the employer.
An individual account where participant contributions, account earnings and medical reimbursements are all tax free. An HSA requires enrollment in an HDHP.
These programs target individuals who cannot otherwise obtain or afford health insurance in the private market primarily due to pre-existing health conditions and are at risk for being uninsured. In general, high risk pools are operated through state established non-profit organizations, many who contract with private insurance companies to collect premiums and administer benefits and pay claims.
Provision in a policy which provides that an insurance company cannot contest the validity of a claim after the policy has been in force for a certain period, usually two or three years.
Incurred But Not Reported claims are those which have been incurred by the insured but have not been submitted to the plan or insurance company for reimbursement (also known as lagged claims).
An insurance health plan that allows absolute freedom in selecting physicians or medical facilities, and, unlike other health plans, self-referral to a specialist. A yearly deductible must be met before coinsurance is paid by the insurance company. Coinsurance is set at a pre-determined rate in which the insurance company pays that percentage of costs. Also called “fee for service”.
A type of HMO which contracts with a physician-controlled entity, usually on a capitulated or discounted fee for service basis to compensate physicians for their medical services. IPAs may also serve non-HMO patients.
The health status of an insurance applicant which makes him/her acceptable to an insurance company (i.e., health, financial conditional, occupation).
The policyholder or party protected by the insurance policy.
The insurance company or party that provides the insurance policy.
The Internal Revenue Service, a division of the U.S. Treasury Dept. that is responsible for the assessment and collection of most federal taxes, except those relating to alcohol, tobacco, firearms, and explosives. Established in 1862, the IRS derives most of its revenues from the collection of corporate and individual income tax.
Insurance designed to protect a business firm against the loss of income resulting from the disability or death of an employee in a significant position.
The time between when a service is incurred and when it is submitted and processed for payment.
Termination of insurance coverage for failure to pay premiums.
The maximum benefit payment provided under a plan or insurance contract.
The services required over a lengthy period of time due to an insured’s chronic illness or disability. It may include skilled nursing care and custodial care, adult day care, or house care servers.
Provision of protection against long-term, chronic or catastrophic illness, which covers a broad area of inpatient and outpatient care, X-ray treatment, drugs, laboratory tests, and often, psychiatric treatment.
A health care system which imposes controls on the utilization of medical services and on the providers who render the care. Managed care is provided through managed indemnity plans; Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), Health Maintenance Organizations (HMOs), or any other cost management environment.
A program that permits the provision of alternative medical care not otherwise available under a health plan for medical conditions that are covered under the plan.
Proposed system in which the government restricts the consumer to purchasing insurance from government-approved carriers.
A specific procedure or coverage that a plan or insurance contract must offer, dictated by state or federal law.
A medical benefits plan available for low-income persons, paid by federal and state government but administered by the state.
A federal program of medical care benefits designed for those permanently disabled or over age 65. Created under the Social Security Medicare law, A. Hospital Insurance Benefits for the Aged and Disabled, a basic plan covering hospital and related care. Persons age 65 are automatically eligible for this plan, but they must enroll before they become covered (entitled). B. Supplementary Medical Insurance Benefits for the Aged and Disabled, a voluntary supplementary plan covering the doctor’s bills and other costs of medical and health services.
A law that created HSAs and Medicare Part D prescription drug coverage.
Supplemental medical expense coverage for expenses not covered by Medicare (A or B).
MHPA is a federal law that requires annual or lifetime dollar limits on mental health benefits provided by a group health plan to be no lower than the annual or lifetime dollar limits for medical and surgical benefits offered by that plan. MHPA applies to employers with more than 50 employees.
An IRS-defined term that helps to determine eligibility for the COBRA subsidy under ARRA.
An employee benefit plan to which more than one employer contributes and is established and maintained through the collective bargaining process.
A trust established by a sponsor that allows small employers in the same or related industries to provide medical insurance under a trust arrangement.
An employee welfare arrangement designed to provide benefits to employees of two or more employers.
An organization that assists state insurance departments and helps draft model laws.
A law that added two additional reasons for taking FMLA leave.
Contracted providers of health care (physicians, hospitals, testing centers, rehabilitation centers, etc.) that have negotiated discount fees for their services in return for higher patient volume. This can apply to HMO, PPO, POS and EPO organizations.
A law that made changes to COBRA, including the optional qualifying event date rule for measuring the period of COBRA coverage.
A right included in an HMO which allows the covered person to obtain non-emergency covered services from a specialist without a referral from the primary care physician or gate keeper.
The maximum amount that an insured is required to pay under a plan or insurance contract.
A type of medication that is available for purchase without the prescription of a licensed health care provider.
The total claims payment made by the plan or insurance company. It does not include any employee cost sharing or provider discounts.
A provider who has agreed to contract with a managed care program to provide eligible services to covered persons.
The governmental entity that insures employer-sponsored pension benefits.
The person or group of persons specifically designated by the terms of the instrument under which the plan is operated or, in absence of a designation, the plan sponsor.
The accounting period utilized by a plan to keep financial records, typically either a calendar year or a fiscal year.
Each time health care services are needed, the patient can choose from different types of provider systems, (indemnity plan, PPO or HMO); each choice may provide different benefit payments.
A written contract of insurance.
Used by insurance companies to combine all premiums, claims and expenses in order to spread the risk of insurance coverage. This process ensures that small employers will not be singled out and unfairly assessed with a large rate increase due to unanticipated medical catastrophic claims of its insured employee(s).
Provides access to continuous health coverage so the insured does not lose insurance coverage due to any change in health or personal status (such as employment, marriage or divorce).
A condition or diagnosis which existed (or for which treatment was received) before coverage began under a current plan or insurance contract and for which benefits are not available or are limited.
A clause in an insurance contract or plan which specifies if benefits will or will not be paid for a pre-existing condition. (Example: “The insured must be covered by the plan for a certain period of time or have gone a certain amount of time without any treatment.”) Additionally, the clause may limit the benefit payable for treatment of pre-existing conditions until a certain time period of coverage has elapsed, usually six months to a year.
The period of time that a group health plan can legally limit your access to the health benefits offered by that plan because of a pre-existing condition.
An organization of participating providers that have agreed to provide their services at negotiated discount fees in exchange for prompt payment and increased patient volume.
An employer-sponsored cafeteria plan that allows participants to pay for health benefits on a pre-tax basis.
A type of HMO plan where participating providers render specific services to the insured in exchange for an advance fixed payment.
Routine office medical care provided by a family physician.
A certification for those in the human resources (HR) profession that is awarded by the Human Resource Certification Institute, indicating a high level of theoretical knowledge and practical experience in HR management sufficient to pass a comprehensive exam.
Individually identifiable health information maintained or transmitted by a covered entity or its business associate.
A physician, hospital, skilled nursing facility, intensive care facility, health care professional or other entity which provides health care services.
An individual who is a covered employee, covered spouse or covered dependent child on the day before a qualifying event or a dependent child who has later been added to COBRA coverage through the HIPAA special enrollment right for birth or adoption.
The maximum amount a plan or insurance contract will consider eligible for reimbursement, based upon prevailing fees in a geographic area.
The practice (illegal in most states) of giving an insurance applicant anything of value as an inducement to purchase or renew an insurance policy. isolved Benefit Services runs into this concept frequently when agents wonder whether paying for our service for a client constitutes rebating. However, what we have found is that most states consider paying for our service as “risk management” instead of rebating. We will still make a point of telling the individual agent to talk to their own Department of Insurance (DOI).
The transfer of the insurance risk to another insurer. Insurer’s self-funded plans generally buy specific and/or aggregate stop-loss coverage to cover losses in excess of certain limits (also known as stop loss). Sometimes when a COBRA issue comes up, we are told that a company is self-funded. So do they still need to consult their carrier for permission/advice? Absolutely, since most “self-funded” plans are still dealing with the reinsurance “carrier.”
A specific amount of money pre-funded and set aside to assure adequate funds to cover future claims. Both insurance companies and self-insured employers must “reserve” in order to preserve cash-flow and protect solvency.
The portion of the insurance premium which is allocated for expenses, administration, commissions, risk charges and profit.
An amendment to an insurance contract limiting, or excluding, an existing coverage for certain conditions (for example, a rider to a policy may exclude coverage for treatment to an applicant’s knee).
Those who work less than 1,000 hours in any 12-month period.
An arrangement under which all or some of the risk associated with providing coverage is not covered by an insurance contract.
A certification for those in the HR profession that is awarded by the Human Resource Certification Institute, indicating a senior level of theoretical knowledge and practical experience in HR management sufficient to pass a comprehensive exam.
A geographic area of operation for a managed care entity.
A law that clarified the period of COBRA coverage in situations involving Medicare entitlement that occurs before the COBRA qualifying event.
An HMO that employs physicians to provide health care services to its members. Staff Models usually operate their own health center or facilities.
A document required by ERISA that notifies participants of major aspects of an employer-sponsored benefit plan.
A law that provided guidelines for COBRA compliance, among other things.
An organization that provides specific administrative duties (including premium accounting, claims review and payment, arranging for utilization review and stop-loss coverage) for a self-funded plan.
The purpose of reform is to eliminate unnecessary practices and testing which are performed defensively by a physician with little or no value to the person seeking treatment. It may also include reasonable limits placed on non-economic damages paid to a patient or beneficiary.
A federal program created by the Trade Act of 2002 that provides certain benefits to workers who are displaced by import competition or shifts of production to other countries, as certified by the DOL.
The percentage of increase used by an insurance company or plan to reflect the projected rise in health care costs. Calculation factors also include inflation, utilization, technology and geographic area.
A plan which usually offers an insured an opportunity to choose between an indemnity plan, HMO and PPO.
To increase the reimbursement paid by a plan or insurance contract, each medical procedure is billed under a separate code as a separate item, instead of part of one overall procedure.
A law that provides employment and benefits protections to employees called up to active military duty.
The number of times a health care service is obtained by an insured during a specific period of time.
A program designed to help reduce unnecessary medical expenses (usually hospital stays) by using preliminary evaluations and patient discharge practices.
The time period between an employee’s date of hire and their eligibility to receive benefits under a plan or insurance contract.
A provision in a plan or insurance contract which relieves the insured of paying the premiums while totally disabled.
Programs or benefits which are introduced to encourage fitness, preventive care and early detection of illness to help reduce the costs of future health care (also known as Preventive Care).
Programs mandated by the states which require employers to provide coverage to compensate employees for work-related injuries or disabilities.