Group Health Insurance Glossary


Accreditation: A “seal of approval” received by a healthcare facility. Having received an accreditation indicates that the facility meets service quality standards set by private, nationally recognized groups that monitor healthcare facilities.

Ambulatory Care: Any type of healthcare service that doesn’t require an overnight hospital stay.

Ancillary Services: Healthcare related services other than those you’ve received from a physician or hospital, including anesthesia, lab work, and x-rays.

Benefit Design: The process by which the benefits or level of benefits that a health plan will offer its members is determined.

Board-Certified: This refers to a physician with specialized training in a particular area of medicine.

Cafeteria Plan: Employee benefit plans that allow employees to choose from an assortment of benefit types in order to create a healthcare plan that best suits their needs. Cafeteria plans are also known as flexible benefit plans.

Claim Form: An application for benefits reimbursement from a health plan.

Claims Administration: The department responsible for processing your insurance claims.

COBRA: The Consolidated Omnibus Budget Reconciliation Act requires every group health plan with twenty or more participants to allow employees to continue their group health coverage for a limited period after a “qualifying event,” such as job loss or reduction of work hours.

Co-Insurance Rate: A percentage that you will have to pay on each medical claim.

Co-Payment: A specific dollar amount that you will have to pay for a specific healthcare service.

Deductible: The flat amount that you will be responsible for annually before your insurance carrier will make reimbursement payments.

Elimination Rider: A health plan amendment that permanently excludes you from coverage for a particular medical condition. Note: There are certain states that do not permit elimination riders.

EPO: The acronym for Exclusive Provider Organization. EPOs are healthcare plans similar in most respects to Preferred Provider Organizations, but they do not provide coverage for out-of-network care.

Formulary: This is a listing of the prescription drugs coverage by a health insurance plan.

Guaranteed Issue: This is a health plan that must allow you to enroll.

HIPAA: The Health Insurance Portability and Accountability Act is a federal law that established an outline for the requirements that group health plans, managed care organizations, and insurance carriers have to satisfy in order to provide insurance coverage in individual and group healthcare markets.

Health Maintenance Organizations: Better known as HMOs, these popular health plans provide comprehensive medical services to their members in return for a fixed, pre-paid fee. When you choose an HMO, you’ll be required to choose a “primary-care physician” who will be responsible for administering your healthcare and making specialist referrals. You will also have to use the doctors and hospitals who are members of your HMO Organization’s network.

Health Savings Accounts: Established by federal legislation passed in late 2003, HSAs combine high deductible health plans with tax-favored savings accounts.

High Deductible Health Plan: A health insurance plan that carries a minimum deductible of $1,050 for individuals and $2,100 for families.

Managed Care Organization: Health plans that lower your healthcare expenses by negotiating savings with a “network” of healthcare providers.

Network Provider: The healthcare providers who have contractual relationships with your insurance carrier. This relationship establishes pre-set charges for specific services, clinical protocols, and overall standards of care.

Open Access: This refers to a health plan provision that guarantees plan members the right to refer themselves to specialists without first having to get approval.

Out-of-Pocket Maximum: The limits set on what you’ll have to pay for your healthcare annually.

Pre-Existing Condition: Any medical condition that you received treatment, medication, diagnosis, or for consultation before the effective date of a new health plan.

Preferred Provider OrganizationPPOs are healthcare benefit programs that will supply you with services at a discounted cost by providing incentives to use designated health providers. PPOs will also provide coverage for health services given by providers who are not a part of your plan network.

Primary Care Physician: Your primary care physician will be your main caregiver, serving as the first “point-of-contact” for your healthcare needs and referring you to specialist providers.

Qualifying Medical Expenses: Any health or medical expenditure that is covered by your health plan.

Referral: The “go ahead” from your primary-care physician that will allow you to see a specialist.

Service Area: The geographic area in which your health plan will accept members.

Urgently Needed Care: The care you’ll receive for unexpected injuries or sudden illnesses that require immediate — but not emergency — medical care. Your primary care physician will generally provide your urgently needed care.

Workers Compensation: The basic health plan that employers are legally required to have in order to cover employees who are injured on the job.