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Actuarial - permalink

Relating to the mathematics of insurance, including probabilities. Actuarial work involves analyzing data to predict with a reasonable degree of accuracy the amount of claims that will be paid. This work ensures that the risks are carefully evaluated and that the premiums charged are reasonable in relation to the benefits provided.

Affordable Care Act - permalink

The federal health care reform law enacted in March 2010. The law was passed in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act" is used to refer to the final, amended version of the law.

Age Band - permalink

Range of ages that determine premium amounts for a health plan.

Annual Limit - permalink

A dollar limits placed on the claims that the health plan will pay over the course of a year.

Balance Billing - permalink

When you receive services from a health care provider that does not participate in your insurer's network, the health care provider is not obligated to accept the insurer's payment as payment in full and may bill you for unpaid amount. This is known as "balance billing."

Children's Health Insurance Program (CHIP) - permalink

The Children’s Health Insurance Program (CHIP) provides coverage to low- and moderate-income children. Like Medicaid, it is jointly funded and administered by the states and the federal government. It was originally called the State Children’s Health Insurance Program (SCHIP).  

Chronic Illness - permalink

An illness that lasts a long time or an illness that will never be cured such as diabetes and arthritis. 

Claim - permalink

A request that you or your health care provider makes to the health plan to pay for a health care service provided to you. Most health plans require claims to be in writing. Health plans require claims to be on a specific standard form. 

COBRA - permalink

Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986. COBRA provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. The law generally covers health plans maintained by private-sector employers with 20 or more employees, employee organizations, or state or local governments. Many states, including Minnesota, have "mini-COBRA" laws that apply to the employees of employers with less than 20 employees.

Coinsurance - permalink

A percentage of a health care provider's charge for which the patient is financially responsible under the terms of the policy.

Community Health Center - permalink

A clinic designated by the United States Public Health Services because of the need for health services in that neighborhood. Also known as a neighborhood health center.

Copayment - permalink

A flat-dollar amount which a patient must pay when visiting a health care provider. For example, a health plan may require that a covered person pay $20 each time they go to the doctor.

Cost-Sharing - permalink

Health care provider charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance and copayments. Balance-billed charges from out-of-network physicians are not considered cost-sharing.

Deductible - permalink

A dollar amount that a patient must pay for health care services each year before the insurer will begin paying claims under a policy. Not all plans require deductibles.

Disease Management - permalink

A broad approach to appropriate coordination of the entire disease treatment process that often involves shifting away from more expensive inpatient and acute care to areas such as preventive medicine, patient counseling and education, and outpatient care. The process is intended to reduce health care costs and improve the quality of life for individuals by preventing or minimizing the effects of a disease, usually a chronic condition.

Emergency Care - permalink

Medical care that is needed immediately to save your life or to prevent serious harm to your health.

Employer-Based Health Plan - permalink

An employee welfare benefit plan that is established or maintained by an employer or by an employee organization (such as a union), or both that provides medical care for participants or their dependents directly or through insurance, reimbursement or otherwise.

External Review - permalink

The review of a health plan's determination that a requested or provided health care service or treatment is not or was not medically necessary by a person or entity with no affiliation or connection to the health plan. PPACA requires all health plans to provide an external review process that meets minimum standards.

Federal Health Reform - permalink

This term is used to refer to the Affordable Care Act as well as all the associated regulations, rules and other guidance issued by federal agencies in order to implement that Affordable Care Act.

Grandfathered Plan - permalink

A health plan that an individual was enrolled in prior to March 23, 2010. Grandfathered plans are exempted from many of the changes required under health reform. New employees may be added to group plans that are grandfathered, and new family members may be added to all grandfathered plans. 

Group Insurance - permalink

A health care plan that is purchased for a group of eligible people, usually by an employer for its employees. In Minnesota there are two forms of group insurance: small group insurance (for groups of 2-50 individuals) and large group insurance (for groups of 51 or more individuals).

Guaranteed Issue - permalink

A requirement that health insurers sell a health insurance policy to any person who requests coverage. Health reform requires that all health insurance be sold on a guaranteed-issue basis beginning in 2014.

Health Care Home (also called Medical Home) - permalink

Health care homes are an innovation in primary care in which providers, families and patients work together to improve the health and quality of life for individuals, especially those with chronic and complex conditions.

Health Insurance - permalink

Financial protection against all or part of the medical care costs to treat illness or injury. Health insurance may also include benefits for preventive health care to help you stay healthy.

Health Maintenance Organization (HMO) - permalink

An HMO is a nonprofit organization which provides comprehensive health maintenance services, or arranges for the provision of these services, to enrollees on the basis of a fixed prepaid sum without regard to the frequency or extent of services furnished to any particular enrollee.

Health Plan - permalink

A policy of health insurance issued by a health maintenance organization, an insurance company, Blue Cross Blue Shield, a fraternal benefit society, or other authorized entity.

Health Reform - permalink

This is a comprehensive term referring to all the legislation and all the activities by both state and federal agencies to improve the health care system. It includes:

•  changes in federal law such as the Affordable Care Act,

•  changes in Minnesota statutes such as the comprehensive package of reforms passed in 2008, also called “Minnesota’s Vision for a Better State of Health”

•  all regulations, rules and guidance issued by both state and federal agencies to implement the various health reform laws.

High Risk Pool - permalink

A health plan that provides coverage for individuals with preexisting conditions who cannot purchase it in the private market. Minnesotans have both a state high risk pool, the Minnesota Comprehensive Health Association (MCHA) , and a federal high risk pool, the Preexisting Condition Insurance Plan (PCIP) , available to them if they are looking for alternatives after having been turned down for coverage in the private market.

HIPAA (Health Insurance Portability and Accountability Act of 1996) - permalink

The federal law enacted in 1996 which eased the "job lock" problem by making it easier for individuals to move from job to job without the risk of being unable to obtain health insurance or having to wait for coverage due to pre-existing medical conditions.

Hospice - permalink

A facility or program that provides care for a terminally ill patient.

Individual Insurance - permalink

A policy of health insurance purchased by an individual rather than a group plan purchased by an employer.

Individual Mandate - permalink

A requirement that everyone maintain health insurance coverage. Health reform requires that everyone who can purchase health insurance for less than 8% of their household income do so or pay a tax penalty.

Individual Market - permalink

The market for health insurance coverage offered to individuals and families other than in connection with a group health plan.

Inpatient - permalink

A person admitted to a health care facility to receive health care services.

Job Lock - permalink

The situation where individuals remain in their current job because they have an illness or condition that may make them unable to obtain insurance coverage if they leave that job. Health reform eliminates job lock by 2014 by prohibiting insurers from refusing to cover individuals due to health status.

Lifetime Limit - permalink

A dollar limit that is placed upon the claims that the insurer will pay over the course of an individual’s life.

Long-Term Care - permalink

Health care services prescribed by a physician and provided in a nursing facility or by a home health agency.

Medicaid (Title XIX) - permalink

A health care program for people who meet certain income and other guidelines. Medicaid is paid for by federal and state dollars. In Minnesota this program is called Medical Assistance.

Medical Assistance - permalink

A health care program for people who meet certain income and other guidelines. It is paid for by federal and state dollars.

Medically Necessary Care - permalink

Health care services that are appropriate for a given diagnosis or condition.

Medicare (Title XVIII) - permalink

A federal health insurance program for people over 65 and for certain people with disabilities.

Medicare Advantage - permalink

An option Medicare beneficiaries can choose to receive most or all of their Medicare benefits through a private insurance company. Also known as Medicare Part C. Plans contract with the federal government and are required to offer at least the same benefits as original Medicare, but may follow different rules and may offer additional benefits. Unlike original Medicare, enrollees may not be covered at any health care provider that accepts Medicare, and may be required to pay higher costs if they choose an out-of-network provider or one outside of the plan's service area.

MinnesotaCare - permalink

A health insurance program for low income Minnesotans who meet income and other eligibility guidelines.

Navigator - permalink

An experienced and knowledgeable person who can assist individuals and small employers in evaluating their coverage options within an Exchange beginning in 2014. This person may not work for an insurer or be paid by insurers for plan enrollments.

Network - permalink

A group of health care providers that form an affiliation and contract as a group with an HMO or insurer.

Nurse Practitioner (NP) - permalink

A registered nurse specially educated and licensed to provide primary and/or specialty care.

Open Enrollment Period - permalink

A specified period during which individuals may enroll in a health insurance plan each year. In certain situations, such as if one has had a birth, death or divorce in their family, individuals may be allowed to enroll in a plan outside of the open enrollment period. Not all plans have an open enrollment period.

Out-of-Network Provider - permalink

A health care provider (such as a hospital or doctor) that is not contracted to be part of a managed care organization’s network (such as an HMO or PPO). Depending on the managed care organization’s rules, an individual may not be covered at all or may be required to pay a higher portion of the total costs when he or she seeks care from an out-of-network provider.

Patient Protection and Affordable Care Act (PPACA) - permalink

Legislation (Public Law 111-148) signed by President Obama on March 23, 2010. One of two laws that make up the Affordable Care Act which are commonly referred to as the federal health reform law.

Physician Assistant (PA) - permalink

A specially trained individual who provides medical care usually provided by a physician.

Physician Clinics - permalink

Physician clinic means any location where primary or specialty outpatient care are provided.

Preexisting Condition - permalink

A health condition that has been diagnosed and/or treated before you apply for health insurance.

Preexisting Condition Exclusion - permalink

A provision of a health plan which excludes coverage of health conditions that existed prior to the effective date of coverage, usually for a limited period of time.

Preferred Provider Organization (PPO) - permalink

A type of managed care organization (health plan) that provides health care coverage through a network of providers. Typically the PPO requires the policyholder to pay higher costs when they seek care from an out-of-network provider. Depending on the type of coverage you have, state and federal rules govern disputes between enrolled individuals and the plan.

Premium - permalink

The amount that you and/or your employer pay for health insurance, usually paid in installments.

Preventive Care - permalink

Health care that focuses on healthy behavior and providing services that help prevent health problems. This includes health education, immunizations, early disease detection, health evaluations and follow-up care.

Primary Care - permalink

Physicians in general practice or in fields such as family practice, obstetrics, pediatrics, and internal medicine.

Primary-Care Physician or Primary-Care Provider - permalink

The health care provider who serves you in your initial contact with the health care system.

Private Insurance - permalink

Private insurance plans include all forms of health insurance that are not funded by the government.

Provider - permalink

A person or an institution that provides health care services.

Qualified Health Plan - permalink

A health insurance policy that is sold through an Exchange. PPACA requires Exchanges to certify that qualified health plans meet minimum standards contained in the law.

Rate Review - permalink

Review by insurance regulators of proposed premiums and premium increases. During the rate review process, regulators will examine proposed premiums to ensure that they are sufficient to pay all claims, that they are not unreasonably high in relation to the benefits being provided, and that they are not unfairly discriminatory to any individual or group of individuals.

Referral - permalink

A direction from your doctor to receive care from a different provider or facility.

Request for Proposal (RFP) - permalink

An invitation for providers of a product or service to bid on the right to supply that product to the entity that issued the RFP.

Respite Care - permalink

Providing patient care so the primary health caregiver can rest or take time off.

Risk Adjustment - permalink

A process through which insurance plans that enroll a disproportionate number of sick individuals are reimbursed for that risk by other plans that enroll a disproportionate number of healthy individuals. The Affordable Care Act requires states to conduct risk adjustment for some non-grandfathered health insurance plans.

Self-Insured Plan (or Self-Funded Plan) - permalink

A program for providing group health care coverage with benefits paid entirely by the employer rather than by an HMO or insurance company.

Small Group Market - permalink

The market for health insurance coverage offered to small businesses – those with between 2 and 50 employees. Health reform will broaden the market to those with between 1 and 100 employees by 2016.

Underwriting - permalink

Assessment of the risk of enrolling an individual or a group in a health plan.

Waiting Period - permalink

A period of time that an individual must wait either after becoming employed or after submitting an application for a health insurance plan before coverage becomes effective and claims may be paid.