Student Health Insurance Glossary
Annual out-of-pocket maximum
A dollar amount set by the plan which puts a cap on the amount of money the insured
must pay out of his or her own pocket for covered expenses over the course of a calendar
Financial reimbursement and other services provided to insured individuals by insurers
under the terms of an insurance contract. An example would be the benefits listed
under a Life or Health Insurance policy or benefits as prescribed by a Workers Compensation
A request for payment under the terms of an insurance policy.
Your share of the costs of a covered health care service, calculated as a percent
(for example, 20%) of the allowed amount for the service. You pay co-insurance plus
any deductibles you owe. For example, if the health insurance or plan's allowed amount
for an office visit is $100 and you've met your deductible, your co-insurance payment
of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Allows terminated employees to continue their group health insurance coverage under
Coordination of Benefits
A situation where identical or overlapping coverage exists between two or more insurance
companies or service organizations.
This is an arrangement where the covered person pays a specified amount for various
services and the health care provider pays the remainder. The covered person usually
must pay his or her share when the service is rendered. Similar to coinsurance, except
that coinsurance is usually a percentage of certain charges where the co-payment is
a dollar amount.
Health care expenses incurred by an insured or covered person that qualify for reimbursement
under the terms of a policy contract.
A flat amount of covered medical expenses that an insured must incur before the insurer
will make any benefit payments under a medical expense policy.
A person for whom the insured has some legal obligation. For most plans, it is the
insured's spouse and/or children. Some plans also allow non-traditional spousal relationships
(significant other, life-partner, etc.) to be considered a dependent with some additional
The process of identifying a disease.
A schedule of prescription drugs approved for use, which will be covered by the plan
and dispensed through participating pharmacies.
The amount of time an employee has to sign up for a contributory health plan.
The abbreviation for Explanation of Benefits form that the insured receives from UHCSR
once a claim has been processed. The Explanation of Benefits form sets out exactly
how the claim was paid and to whom.
When a new drug is put on the market, the pharmaceutical company patents it under
a brand name. The company has the exclusive right to sell the drug under this name,
but once its patent expires, other companies can sell the same drug under its chemical,
or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the
Food and Drug Administration requires generic drug manufacturers to show that a generic
drug "delivers the same amount of active ingredient in the same time frame as the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Under this federal law (known as HIPAA), group health plans cannot deny coverage based
solely on an individual's health status. This law also gives employees who cannot
change or lose their jobs better access to health coverage, guarantees renewability
and availability to certain employees and limits exclusions for pre-existing conditions.
For example, under this law, group health plans must credit any employee the amount
of time that they spent on any health plan prior to the new plan, which is known as
"prior credible coverage." A pre-existing condition will be covered without a waiting
period when an employee joins a new group plan if the employee has been insured for
the previous 12 months with credible health insurance, with no lapse in coverage of
63 days or more. This means that if an employee has been insured for 12 months or
more, the employee will be able to go from one job to another and his or her pre-existing
coverage will remain intact -- without additional waiting periods. However, if an
employee has a pre-existing condition and was not covered previously for 12 months
before joining a new plan, the longest the employee will have to wait for their pre-existing
coverage to be covered is 12 months.
Health Maintenance Organization (HMO)
An HMO is a prepaid medical service plan that provides services to plan members. Medical
providers contract with the HMO to provide medical services to plan members. Members
must use contracted providers. The emphasis is on preventative medicine.
A card given to each person covered under the plan, which identifies him or her as
being eligible for benefits.
A patient admitted to a hospital or other similar medical facility as a resident patient.
The maximum amount of money a plan will pay towards health care services over the
course of the insured's lifetime.
A system of health care where the goal is a system that delivers quality, cost-effective
health care through monitoring and recommending utilization of services, and cost
Managed Health Care Plan
A plan that involves financing, managing, and delivery of health care services. Typically,
it involves a group of providers who share the financial risk of the plan or who have
an incentive to deliver cost effective, but quality, service.
Maximum Out-of-Pocket Costs
The most a member will pay considering co-payments, coinsurance, deductibles, etc.
A group of doctors, hospitals and other health-care providers contracting with a health
plan, usually to provide care at special rates and to handle paperwork with the health
A provider who has not signed a contract with a health plan.
Services provided in the physician's office.
Health care services received outside the HMO, POS or PPO network.
Any medical care costs not covered by insurance, which must be paid by the insured.
A patient who is not a bed patient in the hospital in which he or she is receiving
Over-The-Counter Drugs (OTC)
A drug that can be purchased without a prescription.
A physical condition that existed prior to the effective date of a policy. In many
Health policies these are not covered until after a stated period or time has elapsed.
A specified amount of money that the insurer receives in exchange for its promise
to provide health insurance to an individual or a group.
This type of care is best exemplified by routine physical examinations and immunizations.
The emphasis is on preventing illnesses before they occur.
Basic health care provided by doctors who are in the practice of family care, pediatrics,
and internal medicine.
A cost containment measure that provides full payment of health benefits only when
the hospitalization or medical treatment has been approved in advance.
Reasonable and Customary Charges
The charge for medical services which refers to the amount approved by the Medicare
Carrier for payment. Customary charges are those which are most often made by a provider
for services rendered in that particular area.
Occurs when a physician or other health plan provider receives permission to consult
another physician or hospital.
A method of ranking sick or injured people according to the severity of their sickness
or injury in order to ensure that medical and nursing staff facilities are used most
The process of selecting risks and classifying them according to their degrees of
insurability so that the appropriate rates may be assigned. The process also includes
rejection of those risks that do not qualify.
Urgent care is appropriate when a medical urgency arises which necessitates immediate
care, but has not reached the level of extreme emergency. Most managed care plans
require you to seek urgent care at a participating urgent care facility or hospital.
Usual, customary and reasonable fee
The maximum dollar amount of a covered expense that is considered eligible for reimbursement
under a major medical policy.