GLOSSARY OF HEALTH INSURANCE TERMS

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Access — the patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care.

Accreditation — the process by which an organization recognizes a provider, a program of study or an institution as meeting predetermined standards. Two organizations that accredit managed care plans are the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO). JCAHO also accredits hospitals and clinics. The Commission on Accreditation of Rehabilitation Facilities (CARF) accredits rehabilitation providers.

Accrual — the amount of money that is set aside to cover expenses. The accrual is the plan's best estimate of what those expenses are, and (for medical expenses) is based on a combination of data from the authorization system, the claims system, lag studies, and the plan's prior history.

Administrative Costs — costs related to utilization review, insurance marketing, medical underwriting, agents' commissions, premium collection, claims processing, insurer profit, quality assurance programs, and risk management. Administrative costs also refer to certain allowable costs on hospital Centers for Medicare and Medicaid Services (CMS) cost reports, usually considered overhead.

Adjudication — the exercise of judicial power by hearing, trying and determining the claims of litigants before the court. Processing claims according to contract.

Accidental Death Benefit — a provision added to an insurance policy for payment of an additional benefit in case of death by accidental means. It is often referred to as double indemnity.

Administrator — (Employee Benefit Plans) Under ERISA, the person designated administrator by the instrument under which the plan operates. If the administrator is not designated, administrator means the plan sponsor. If the administrator is not designated and the plan sponsor cannot be identified, the administrator may be the party prescribed by regulation of the secretary of labor. The administrator’s responsibilities are as follows: 1. Act solely in the interest of plan participants and beneficiaries, and for the exclusive purpose of providing benefits and defraying reasonable administrative expenses. 2. Manage the plan’s assets to minimize the risk of large losses. 3. Act in accordance with the documents governing the plan.

Adult Day Care — provision during the day, on a regular basis, of a range of services that may include health, medical, psychological, social, nutritional and educational services that allow a disabled person to function in the home or at a center.

Allowable Charge — the maximum charge for which a third party will reimburse a provider for a given service. An allowable charge is not necessarily the same as either a reasonable, customary, maximum, actual, or prevailing charge.

Ambulatory Surgical Center — any public or private establishment with an organized medical staff of physicians; with permanent facilities that are equipped and operated for the purpose of performing surgical procedures; and which does not provide services for patients to stay overnight.

Americans with Disabilities Act — a law enacted in 1990 that prohibits discrimination against persons with disabilities in areas such as terms and conditions of employment. Requires employers to make reasonable accommodations to enable employees with disabilities to perform the essential parts of a job.

Anesthesiologist — a physician who specializes in providing anesthetics (local or general) to patients undergoing surgery or other procedures.

Assignment of Benefits — the payment of medical benefits directly to a provider of care rather than to a member. Generally requires either a contract between the health plan and the provider, or a written release from the subscriber to the provider allowing the provider to bill the health plan.

Assisted Living Facilities — shared and supervised housing for those who cannot function independently. Various types of homes serve those who need minimal support to those more severely impaired.

Attending Physician — the physician who is in charge of your care while your are hospitalized. Though medical students, residents and other doctors may treat you, the Attending Physician is your physician of record while you are hospitalized.

Automatic Enrollment — employers can enroll all eligible employees in a plan and begin participant deferrals without requiring the employees to submit a salary deferral request. Plan design specifies the percentage of earnings to be contributed and how these deferrals will be invested; participants can generally change the percentage and allocations if they stay in the plan. Employees who do not wish to participate in the plan must actively file a request to be excluded from the plan. Also known as negative enrollment.