Trademark Insurance Agency

Description

Access Acquisition Cost Activities of Daily Living (ADLs) Actual Charge Actuary Acute Care Adjusted Average Per Capita Cost (AAPCC) Adjusted Community Rate (ACR) Administrative Services Only (ASO) Administrator Adult Day Care Adverse Selection Aid to Families with Dependent Children (AFDC) Agent Aggregate Amount (limit) Ageism Alternate Care Benefit Alternative Care Benefit Alternate Care Facility Alzheimer's Disease Ambulatory Care Ancillary Services Annual Benefit Cap Approved Amount Assessment Assignment Assignment of Benefits Assisted Living ASO Attachment Point Authorizations Average Length of Stay Balance Billing Benchmark Beneficiary Benefit Benefit Increase Options Benefit Period Cafeteria Plan Capitation Carve-Out Case Management Centers of Excellence Chronic Care Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Claim Closed Panel Coalitions COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) Cognitive Impairment Co-insurance Commission Community-Rated Community-Rating Competitive Medical Plans (CMPS) Concurrent Review Congregate Housing Conversion Privilege Coordination of Benefits (COB) Co-payment Cost Containment Cost Sharing Cost Shifting Coverage Covered Expense(s) Current Procedural Terminology (CPT) Custodial Care Facilities Customer Deductible Defense Medicine Dementia Diagnosis-Related Groups (DRGs) Discharge Planning Divestment Dual Choice Durable Power of Attorney Eligible Expense(s) Elimination Period Employee Retirement Income Security Act of 1974 (ERISA) Enrollee Evidence of Insurability Exclusion Exclusive Provider Organization (EPO) Expected Claims Experience Experience-Rated Explanation of Benefits (EOB) Extended Benefits Federally Qualified Federally Qualified Health Center Fee-for-Service Reimbursement Fee Schedule Fiduciary Fixed Costs Flexible Spending Accounts Formulary Fraud Freestanding Plan Fully Insured Plan Gatekeeper Gatekeeper Question Geriatrics Grace Period Global Fees Group-Model HMO Guaranteed Issue Underwriting Guaranteed Renewable Health Alliances Health Insurance Purchasing Cooperatives (HIPCS) Health Care Financing Administration (HCFA ) Health Care Prepayment Plan (HCPP) Health Insurance Purchasing Cooperatives (HIPCS) Health Maintenance Organization (HMO) Home and Community-Based Care Benefits Home Health Services Hospice Hospital Bill Audit Hospital Indemnity Insurance Inability to Perform Activities of Daily Living Incontestability Incurred But Not Reported (IBNR) Indemnity Insurance Individual or Independent Practice Association (IPA) Institutionalization Instrumental Activities of Daily Living (IADLs) Insurability Integrated Coverage Intermediate Care Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Lagged Claims Lapse Lifetime Aggregate or Maximum Long-term Care (LTC) Long-Term Care Facility Malpractice Malpractice Reform Managed Care Managed Competition Managed Indemnity Mandate Mandated Benefits Medicaid Medical Necessity Medicare Medicare-Approved Amount Medicare Part A (Hospital Insurance) Medicare Part B (Medical Insurance) Medicare-Qualified Providers Medicare Risk Plan Medicare Select Medigap-Medicare Supplement Insurance Mental Health Services Military Health Services System (MHSS) Multiple Employer Trust (MET) Multiple Employer Welfare Arrangement (MEWA) Multiple Provider Arrangement Multi-specialty Group Practice National Association of Health Underwriters (NAHU) National Association of Insurance Commissioners (NAIC) National Committee on Quality Assurance (NCQA) Negotiated Fees Network or Mixed-Model HMO Network Providers Non-Forfeiture Benefits Non-Network Providers Omnibus Budget Reconciliation Act (OBRA) Open-Ended HMO Open Panel Out-of-Network Care Out-of-Pocket Expenses Out-of-Pocket Maximum Outcome Measurement Overutilization Paid Claims Partial Capitation Risk Contracts Participating Provider Per Review Per Diem Per Member Per Month (PMPM) Personal Care Advocate Physician-Hospital Organization (PHO) Plan of Care Play or Pay Point of Service Plans (POS) Pool (ing) Portability Practice Guidelines Pre-authorization Pre-certification Pre-existing Condition Pre-existing Condition Clause Preferred Provider Organization (PPO) Premiums Premium Tax Prepaid Group Practice Prevailing Charges Preventive Medicine Primary Care Primary Care Case Management Primary Care Physician (PCP) Profiling Prospective Review Protocol Providers Qualified Provider Quality Assurance Readmission Reasonable and Customary Rebating Referral Referral Pool Rehabilitation Reinsurance Reserves Resource-Based Relative Value Scale (RBRVS) Retention Retrospective Claim Review Rider (Exclusion) Risk Risk Adjustment Risk Contract Risk Sharing Second Surgical Opinions Self-Insurers Self-Funding Self-Referral Service Area Set Aside Seventy-five/twenty-five (75/25) Rule Skilled Nursing Facilities Social Security Act Specialty Managed Care Arrangements Specialty Physicians Specified Disease Insurance Specified Low-Income Medicare Beneficiary (SLMB) Spend Down Staff Model HMO Stakeholders Stop-Loss Insurance Subacute Care Supplementary Coverage Third-Party Administrator (TPA) Tort Reform Total Disability Trend Factor Triggers Triple Option Plan Twenty-four (24-hour) Coverage Unbundled Unbundling Underwriters Usual, Customary, and Reasonable (UCR) Fees Utilization Utilization Review (UR) Vendors Waiting Period Waivers Waiver of Premium Withhold Arrangements Workers Compensation Insurance Wrap-Around Coverage Access : Right to enter or use health care services. Acquisition Cost : The cost to an insurer to acquire new business. It includes costs such as underwriting the risk, issuing a new policy, paying commissions and overhead or office expenses. Activities of Daily Living (ADLs): Everyday activities which are used to measure an individual's ability to function independently. ADLs define the disability in long term care insurance. The loss of some number of ADLs is an insuring or triggering event in all long term care policies. In California, Senate Bill 1943 established seven standard activities of daily living (eating, bathing, dressing, toileting, continence, transferring, ambulating) for any LTC policy that purports to cover home care in it's provisions. A loss of 2 to 7 of the ADLs will qualify an insured for benefits. There are LTC programs in California that do not comply with S.B.1943 (California Partnership and CALPERS). These programs have more stringent insuring clauses. ADLs and the loss necessary to trigger benefits may vary from state to state. Additionally, despite standardization, companies choose to define the inability to perform an ADL differently. The NAIC is working to set national standards for ADL definitions. Actual Charge : The amount a physician or supplier actually bills for a particular medical services or supply. Actuary : 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. Acute Care : Care for illness or injury that develops rapidly, has pronounced symptoms ad is finite in length. Traditional medical insurance, Medicare and Medicare supplements are designed to provide coverage for acute illness. Adjusted Average Per Capita Cost (AAPCC): Health Care Financing Administration (HCFA) basis of payment to HMOs and CMPs. Adjusted Community Rate (ACR): Uniform capitation rate that is charged to all enrollees in a plan based on adjustments for risk factors such as age and sex. Administrative Services Only (ASO): 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 of insurance protection. The usual expenses covered include claims processing, plan design advice and printing benefit booklets. These contracts are usually entered into by large employers who can afford the risk of providing insurance protection with their own money. Administrator : 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, the ERISA considers the pan sponsor to be the plan administrator. Adult Day Care : Social, recreational and/or rehabilitative services provided for persons who benefit from daytime supervision. An alternative between care in the home or in a institution. Adverse Selection : 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. Aid to Families with Dependent Children (AFDC): Public assistance program that provides payment to families with children 18 years of age and under who have an income below a defined poverty line. Agent : Licensed by the state, performs the functions for sole proprietors and small businesses that Human Resource Departments do for larger businesses, gathers census data, prepares proposals, makes presentations to businesses, explains benefits to employers, and employees, does field underwriting when required, delivers policies and certificates, assists in handling claims, performs other related tasks required by the employer or sole proprietor. Aggregate Amount (limit): Maximum amount of total losses for which a plan sponsor (employer) is liable for any one-plan year. Ageism : Prejudice against people because of their age. Alternate Care Benefit : Payment for a special arrangement of services specifically designed to allow the person to reside in a setting other than a nursing facility (i.e. services to provide assistance, capital improvements such as a ramp, and/or durable medical support. Alternative Care Benefit : payment for a special arrangement of services specifically designed to allow the person to reside in a setting other than a nursing facility (i.e. services to provide assistance, capital improvements such as a ramp, and/or durable medical equipment. Alternate Care Facility : (1) A hospice; or (2) a place that provides ongoing care to inpatients in one location and which (a) provides 24-hour care and services sufficient to support needs resulting from inability to perform activities of daily living or cognitive impairment; (b) has a trained and ready-to-respond employee to provide such care; (c) provides three meals a day and accommodates special dietary needs; (d) is appropriately licensed or accredited; (e) has formal arrangements for the services of a physician or nurse to provide emergency medical care; and (f) has appropriate procedures for handling administering drugs. Alzheimer's Disease : A form of organic dementia resulting in premature mental deterioration, first described in 1906 by German neurologist, Alois Alzheimer. In California, as well as most of the rest of the United States, Alzheimer's Disease is considered a cognitive impairment, thus triggering benefits under long term care insurance policy. Ambulatory Care : Medical services provided on an outpatient (non-hospitalized) basis. Services may include diagnosis, treatment, surgery, and rehabilitation. Ancillary Services : Health care services conducted by providers other than physicians and surgeons. These will usually include such services as physical therapy and home health care. Annual Benefit Cap : Maximum amount paid for specific medical services or total medical services. Approved Amount : The amount Medicare determines is reasonable for a service covered under Medicare Part B. It may be less than the actual charge. For many services, including physician services, the approved amount is taken from a fee schedule that assigns a dollar value to all Medicare-covered services that are paid under that fee schedule. Assessment : A determination of physical and/or medical status by a health professional based on established medical guidelines. The assessment is a central component in home care coverage's and the payment of home care claims. Upon the triggering of benefits, due either to the loss of some number or activities of daily living or a cognitive impairment, an assessment is performed by a multidisciplinary team. This "team" usually spearheaded by the insured's physician, determines the level of functional incapacity and develops a plan of care that will be followed in assisting the insured in the performing the ADLs and IADLs (instrumental activities of daily living). Assignment : An arrangement whereby a physician or medical supplier agrees to accept the amount approved by Medicare as full payment for services and supplies under Part B. Medicare usually pays 80% of the approved amount directly to the physician or supplier after the beneficiary meets the annual Part B deductible of $100. The beneficiary pays the other 20 percent. Assignment of Benefits : When the insured authorizes the insurer or claims payer to pay benefits directly to the medical care provider. Assisted Living : A non-medical institution providing room, board, laundry, some form of personal care and usually recreational and social services. Licensed by state departments of social services, these facilities exist under several names including domiciliary care facility,, sheltered house, board and care, community based residential care facilities and alternate care facilities. ASO : A type of contract with an insurance company or a third party administrator that provides an employer with administrative service. It can include coverage for a certain amount of claims risk. The usual administrative expenses include claims processing, plan design advice and printing benefit booklets. Large employers who can afford the risk of providing insurance protection with their own money usually enter into these contracts. Attachment Point : For aggregate stop-loss insurance, it is the point at which the stop-loss insurance carriers begin to reimburse the employer based upon the cumulative total of claims paid within a policy year. Authorizations : Consent or endorsement by a primary care physician for patient referral to ancillary services and specialists. Average Length of Stay : One measure of use of health facilities, reported as an average number of inpatient days spent in a hospital or other health care facility per admission or discharge. It is calculated as follows: total number of days in the facility for all admissions during a particular period divided by the number of admissions during the same period. Average lengths of stay vary and are measured by age, specific diagnosis, or sources of payment. Back to top

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