Insurance definitions & glossary

The best place to look for Insurance definitions & glossary  is in an actual EOC – Evidence of Coverage  (specimen – Platinum) – Policy. Be sure to check your ACTUAL EOC for your specific question.

See our definitions, video’s, guides, etc. below and on the sides.

Numerous other Medical, Legal & Insurance Dictionaries

CA Dept of Insurance Glossary

CMS – Medicare

Medicare Part D Rx Guide Definitions # 11109

AB 1083 Definitions – Small Employer Health Care Reform Legal Dictionary Lectlaw Medicare Glossary

Health Net 6  page glossary

Español (Spanish)

Court Site

Legal Dictionary Lectlaw

Medi-Cal – Helpful words to know

Department of Labor – Health Benefits Advisor   ***   Glossary

Texas DOI Glossary

Glossary of Employee Benefit Terms

State of CA Insurance Dept.

CA DOI – Health Insurance Terms

Glossary – Annuity Advisors LOMA


Acupuncture coverage, including coverage for traditional Chinese herbal supplements, is an option available to employer groups. Health Net has contracted with American Specialty Health Plans (ASHP) to administer acupuncture services and traditional Chinese herbal supplements to Health Net members. Members who have the coverage may obtain acupuncture services through the ASHP network of participating acupuncturists without a referral from the participating physician group (PPG). All acupuncture services, except the initial examination and emergency services, require authorization by ASHP.

Adjudication The process used by health plans to determine the amount of payment for a claim. Allergy Treatment Allergy testing, allergy immunotherapy, and allergy injection services are covered under all plans. Some plans also cover allergy serum. Allergy treatment is covered when it is indicated by standard medical practice and is subject to scheduled copayments. Allowable Charge The maximum fee that a health plan will reimburse a provider for a given service. Ambulatory Services Services performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed medical center. Also called Outpatient Services.See also: Outpatient.   Ambulatory Surgery Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.See also: Outpatient Surgery. Appeals The process used by a member to request that the health plan re-considers a previous authorization or denial decision. Authorization See Prior Authorization.

Adverse Selection 

Adverse selection occurs in health insurance when there is an imbalance of high-risk, sick policyholders to healthy policyholders. The imbalance can happen due to sick individuals, who require more insurance, using more coverage and purchasing more policies than the healthy individuals, who need less coverage and may not buy a policy at all. * NAIC 16 pages on Adverse Selection and ACA *

Balance Billing

is when an insurance plan covers less than what a doctor, hospital, or lab service wants to be paid.. The health-care provider demands, bills the balance from the patient. Uncertain and fearing the calls of a debt collector, the patient pays up. business

Visit our NEW website on ER prohibition of Balance Billing.

While “balance billing” is regulated in eight states, legislation to regulate the practice in California has “repeatedly died” in the state Legislature medical news California DMHCPress Release on Prohibition of Balance Billing in Emergency Rooms 10/2008

See also: Negotiated Fees – Rates

SB 981 This bill would also prohibit a noncontracting emergency physician from seeking payment from individual enrollees for covered emergency medical services he or she rendered, except for allowable co payments and deductibles, and would require the physician to seek reimbursement solely from the enrollee’s health care service plan or the plan’s contracting risk-bearing organization. The bill would require a health care service plan that becomes aware that one of its enrollees has been billed in violation of these provisions to report that violation to the department. The bill would also provide that an enrollee shall have no obligation to pay an amount billed in violation of these provisions.

Bill Number: SB 697 Topic: Provider Balance Billing for Members of Healthy Families and AIM Statute(s) Impacted: Added 12693.55 and 12698.26 to the Insurance Code Effective Date: January 1, 2009 Summary: This bill prohibits providers of health care from seeking to collect any amounts from Healthy Families and Aid for Infants and Mothers Program enrollees for covered services, except authorized copayments.

Balance Billing

See also Dual Coverage


Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.

Benefit Period

Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.

Brand Name Drug

A prescription drug that has been patented and is only available through one manufacturer.

See also: Generic Drug.

Case Management

A program that assists the member-patient in determining the most-appropriate and cost effective treatment plan. Case management is usually provided to patients who have prolonged expensive or chronic conditions. The program helps determine the treatment location (hospital, other institution or home) and may authorize payment for such care if it is not covered under the member’s benefit agreement.

Certification See Pre-Certification.
Certificate of Creditable Coverage
Chemotherapy Treatment of malignant disease by chemical or biological antinoeplastic agents.
Chiropractic Care

An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.

Claim A request for payment for benefits received or services rendered.
Co-payment (or co-pay) Click on link to view our page on Co-Pays, Deductible and Maximum Out of Pocket

Consolidated Omnibus Budget Reconciliation Act: a federal law that requires most employers with 50 or more employees to provide continuation of coverage for members as prescribed by current federal law.


Click on link to view new page

Coinsurance maximum OOP Click on link to view new page

When a former plan member has lost eligibility because of a qualifying event (as defined by law), coverage identical to that currently being provided to “similarly situated” (AB 1672)active employees must be continued without a lapse if requested by the member. To illustrate, a member, who had Plan A previously, would continue to have the benefits of Plan A as a COBRA member. Examples of qualifying events include: termination of the subscribing member’s employment, divorce or legal separation from the subscribing member, loss of eligibility of the subscribing member’s dependent child, death of the subscribing member.

How to determine Similarly Situated Employees

Contraception The use of contraceptive devices or services and supplies that prevent pregnancy.
Contract or Subscriber Contract A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage. One subscriber may have coverage under two contracts e.g., one for health and one for dental. Contract or Subscriber contract may also be referred to as Benefit Certificate or Certificate of Insurance, Evidence of Coverage, Health Benefit Contract or Policy.
Conversion Option The exercise of an option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group, typically at retirement. This may cause you to lose COBRA and HIPAA rights
Coordination of Benefits (COB)

The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus “coordinated” between the two health plans.

Covered Services Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense, which will be considered in the calculation of benefits.
Custodial Care Care that is provided primarily to meet the personal needs of the patient. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine, or any other care, that does not require continuing services of medical-trained personnel.
Customary and Reasonable (C&R) The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called “Usual, Customary and Reasonable” (UCR).More
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Day Treatment Center An outpatient psychiatric facility, which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.
Deductible Click on link for new page


Deductible CarryoverDental CareCovered Services which are necessary and appropriate for the treatment of your teeth and gums and supporting structures according to a licensed professional dentist or dental policies which meet professionally recognized standards of practice.DependentPerson (spouse or child) other than the subscribing member who is covered under the subscriber’s evidence of coverage or benefit certificate. May also be referred to simply as “Member” or “Beneficiary”.See also: Member.Dictionaries

Diagnostic Tests Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.Disability Insurance  Insurance Code Definition benefits and how to obtain coverage  

Domestic PartnerDrug Formulary or Recommended Drug List (RDL)

A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. See: /general/plans/supplemental/drug.asp

Durable Medical Equipment (DME) Mechanical devices, equipment and supplies, which enable a person to maintain functional ability. Also called Medical Equipment. Medicare Brochure

Effective Date The date that you become covered or entitled to receive the benefits provided under the Plan.
Emergency Care

An injury or sudden, unexpected illness (including severe pain and active labor) of sufficient severity that if the member does not receive immediate treatment, it could present a serious threat to his or her health, could seriously impair physical functions, or could cause a serious dysfunction of any organ or body part if immediate medical treatment is not received.


An individual who is enrolled and eligible for coverage under a health plan contract. This term encompasses both the subscriber and any of his/her covered dependents, each of whom may also be referred to as a “Member”.

See also: Member.

Evidence of Coverage (EOC)

Specific conditions or circumstances that are not covered under the health plan benefit agreement. It is very important to consult the health plan benefit agreement (may also be called the Evidence of Coverage, Certificate, or Subscriber Contract) to understand what services are not covered benefits.

Experimental Procedures Procedures that are mainly limited to laboratory research.
Expiration Date The date indicated in the contract as the date coverage expires.
Explanation of Benefits (EOB)

A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, and the claims appeal process.

Formulary See Drug Formulary or Recommended Drug List (RDL).
Generic Drug A drug, which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand drug. Read more about Generic Drugs here: also: Brand Name Drug.
Health Benefit Plan The plan described and is defined in the health plan benefit contract (may also be referred to as Evidence of Coverage, Subscriber Contract or Certificate), which contract delineates the set of covered health care services and benefits offered, and the health care provider network available, to the member.
Health Maintenance Organization (HMO) A type of health care plan under which the enrollees receive all the medical services under a Health Benefit Plan through a specific group of participating doctors and hospitals. Difference between HMO and PPOFrom Page 2 of Blue Shields Individual 50 Page Brochure See our HMO, EPO & PPO page
HMO See Health Maintenance Organization (HMO).
Home Health Care Health services rendered in the home to an individual who is confined to the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional care, but who do need nursing services or therapy, medical supplies and special outpatient services.See also: Outpatient.
Home Infusion Therapy The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.
Hospice A facility or service that provides care for the terminally ill patient and who provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
Hospital An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.See also: Emergency Care, Inpatient, Outpatient.
I.D. Card / Identification Card

A card issued to a subscriber and possibly his/her dependents, which allows the subscriber to identify himself or his covered dependents to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.


Immunizations and injections that are recommended by guidelines published by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service or the American Academy of Pediatrics (AAP).

In-Network Refers to the use of providers who participate in the health plan’s provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee’s out-of-pocket expense.
Indemnity A tradition health insurance plan that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also know as fee-for-service plans. These plans generally do not have a specific provider network.
Independent Contractor 1099 View our page on Independent Contractor vs 1099 employee – and other definitions
Infertility Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception. Also includes the presence of a condition recognized by a physician as the cause of infertility.
Infusion Therapy Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition which is the delivery of nutrients into the gastrointestinal tract by tube.
Inpatient Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
Investigational Procedures Procedures that have progressed to limited use on humans but are not widely accepted as proven and effective procedures within the organized medical community.
K Knox-Keene Health Care Service Plan Act of 1975 The Knox-Keene Health Care Service Plan Act of 1975, as amended, is the set of laws passed by the State Legislature to regulate HMOs within the State
Late Enrollment


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Managed Care Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires pre-authorization of certain services.See also: Health Maintenance Organization (HMO).
Material Fact CA Insurance Code on Disclosure
Maternity Care Health care provided during pregnancy, including care rendered during the pre and post-natal phase of pregnancy, as well as care rendered throughout the entire course of pregnancy, continuing through to infant delivery and circumcision.
Medical Equipment (DME) See Durable Medical Equipment (DME).
Medically Necessary Services or supplies provided by a licensed health facility or health professional,whichare determined by the health plan company and its contracting or employedPhysicianGroupto be: Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness or injury. Learn More
Not Experimental or Investigational.

Member An individual or dependent who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

Mental Health / Behavioral Health Conditions that affect thinking and the ability to figure things out and that affect perception, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking or distortions of the way things are perceived (seeing or hearing things that are not there.) Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, and highly agitated or unusual behavior.California Mental Health Parity Act Federal AB 88

Moral Hazard 

Moral hazard is the idea that a person who is insured will take on more risk and use more of a service than they would if they were not covered. In health insurance, moral hazard is the concept that an insured person will accept more risky health situations and then use more health care because they know that the cost will pass along to the insurer. Value Penguin

Network The doctors, clinics, hospitals and other medical providers that a health plan contracts with to provide health care to its members. In a PPO or HMO, members are generally limited to network providers for full coverage of their health costs.See also: Health Maintenance Organization (HMO), Out of Network, Preferred Provider Organization (PPO).How Aetna Pays Out of Network Providers
Network Provider Physicians, Hospitals or other providers of health care who have a written agreement with the health plan to participate in the network. Providers are listed in the Preferred Provider Directory given to each Member upon enrollment and periodically updated.
Negotiated Rates Negotiated Fee Rate is
Balance Billing Balance Billing  This means that you pay the full cost of … care (at our negotiated rates) until your annual deductible has been met.Health Net Brochure page 9Medicare Allowances – CPT Codes Pending Legislation AB 1321 2005-2006 Session – MD’s must bill through hospital, when hospital is a contracted (HMO – PPO) provider and can’t send separate bills PDF


Analyses Assembly Committee


If it seems too good to be true, it probably is. Nationwide, the health insurance marketplace is facing tough times. The cost of health insurance is rising. Those seeking to make a profit by selling fraudulent health insurance claim that state insurance laws don’t apply. These entities recruit insurance agents to sell “ERISA plans” or “union plans” that falsely claim to be exempt from state law. Click on link to find information from National Association of Insurance Commissioners (NAIC) to help you protect yourself against illegal health insurance plans DOL Site on MEWA *  DOL Investigations & Enforcement

Non-Participating ProviderA medical provider who has not contracted with a health plan as a participating provider.

Occupational Therapy Treatment to restore a physically disabled person’s ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.
Open Enrollment
Out of Network

The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverage’s can go out-of-network, but will pay some additional costs.    Specimen Policy Definition page 168

Out of Network Problems, Solutions and Work Arounds

See also: Health Maintenance Organization (HMO), Network, Point of Service (POS), Preferred Provider Organization (PPO).

Out-of-Pocket Maximum Refers to the maximum amount that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.out-of-pocket maximum. This means that once your expenses reach a certain amount in a given calendar year, the reasonable and customary fee for covered benefits will be paid in full by the insurer.   Specimen Policy Page 5      56  
Outpatient A patient who is receiving care at a hospital, physician office or other health facility without being admitted to the facility for an overnight stay. The term “ambulatory” is often used to describe outpatient care.
Outpatient Surgery Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.


Partial Day Treatment A program offered by appropriately-licensed psychiatric facilities that include either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.
Participating Provider A physician, hospital, pharmacy, laboratory, or other appropriately licensed facility or provider of health care services or supplies, that has entered into an agreement with a managed care entity, or HMO, to provide services or supplies to a patient enrolled in a health benefit plan.
PCP See Primary Care Physician (PCP).
Physical Therapy Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.
Point of Service (POS) A type of health benefit plan that allows enrollees to go outside the health plan’s provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.
Pre-Authorization A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.   Learn More in specimen policy page 127      132      

Applies to specified services that require review and approval prior to the expense for such services being incurred. If a service is not Pre-Certified, benefits paid for that service will be reduced in accordance with the provisions of your Certificate of Insurance or Evidence of Coverage.

Pre-Existing Condition
Preferred Provider Organization (PPO) A type of health benefit plan designed to give enrollees incentives to use health care providers designated as “preferred providers”, but that also give substantial coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP, although some HMOs with a POS feature may allow this as well. See also HMO See our HMO, EPO & PPO page
Prescription A written order or refill notice issued by a licensed medical profession for drugs which are only available through a pharmacy.
Preventive Care Office visits for the evaluation and management of the member’s physical development for prevention of future medical problems.
Primary Care Physician (PCP) A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient’s regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.
Prior Authorization The process of obtaining advance approval before receiving certain health care services covered under a Certificate of Insurance or Evidence of Coverage.See also: Pre-Authorization.
Prosthetic Devices A device which replaces all or portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.
Provider A licensed health care facility, program, agency, physician or other health professional that delivers health care services.
Provider Network The set of providers contracted with a health plan to provide services to the enrollees.See also: Network.
Qualifying Event See late enrollee Special Enrollment AB 1672 Requirements DOL HIPAA Q & A ERISA TITLE 29CHAPTER 18SUBCHAPTER I Subtitle B part 6 1163 Westlaw Cases 1163
Qualified Beneficiary Qualified Beneficiary 1167
Radiation Therapy Treatment of disease by x-ray, radium, cobalt or high energy particle sources.
Reasonable and Customary A charge that falls within the common range of services by a majority of providers for any procedure in a given geographic region, or which is justified based on the complexity or the severity of the treatment for a specific case. Specimen  Policy Page 171
Referral A recommendation by a physician that an enrollee receive care from a specialty physician or facility.
Respiratory Therapy Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.
Qualifying Event Certain events that would ordinarily cause an individual to lose health coverage. The type of qualifying event will determine who the qualified beneficiaries for the qualifying event are and the length of time COBRA continuation coverage is available. See also Special Enrollment – Our Webpage on Health Care Reform Special Events For more information, see Questions and Answers: Recent Changes in Health Care Law. Source
Second Opinion The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
Service Area The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.
Similarly Situated Non-COBRA Beneficiaries

The group of covered employees, their spouses or dependent children who are covered under a group health plan maintained by the employer or employee organization. This group is receiving their benefits under the group plan and not through COBRA continuation coverage. They are most similarly situated to the circumstances of the qualified beneficiary immediately before the qualifying event. Source

AB 1672 def. similar DOL Explanation of HIPAA Protections Similarly Situated Individuals – Protections How to determine Similarly Situated Employees

Skilled Nursing Facility (SNF) A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
Speech Therapy Treatment of the correction of a speech impairment which resulted from birth, or from disease, injury, or prior medical treatment.
Special Enrollment Special Enrollment under Health Care Reform



Department of Labor Glossary

Federal Definition Title 42 300 gg f

See also late enrollee Qualifying Event AB 1672 Requirements Federal Code of Regulations 146.117 Special Enrollment Periods

Spin-Off Group:

New company formed by employees leaving an established group to form a new company with a new owner, and potentially, some additional employees who are not from the established group. If two or more employees they are GUARANTEED issue under Ins. Code 10700

Subscriber The individual in whose name a contract is issued or the employee covered under an employer’s group health contract. The subscriber can enroll dependents under family coverage.
Subscriber Contract See Contract or Subscriber Contract.
Substance Abuse / Chemical Dependency Alcoholism, drug addiction, or other chemical dependency problems.
Tier Rating
Letter T
Urgent Care

Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or sever pain, such as a high fever. urgent

Usual, Customary and Reasonable

A “usual” charge is the amount that is most consistently charged by an individual physician for a given service. A “customary” charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A “reasonable” charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under an UCR Program, the payment is the lowest of the actual billed charge, the physician’s usual charge or the area customary charge for any given covered service.

See also: Customary and Reasonable (C&R).

Utilization Management

The entire program of systems designed to ensure that members receive quality, medically necessary health care services at the appropriate level of care in a timely, effective, and cost efficient manner. It includes pre certification, concurrent review, discharge planning, care management and retrospective review.


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wages Employment Development Department EDDweb site:



What are wages?All money, the value of meals and lodging, or other goods and services provided to an employee as payment for personal services are “wages.” Payment may be by private agreement, consent, or mandated by law. The method of payment does not change the taxability of wages paid to employees, no matter what terminology is used. Payments by the day, by the hour, by “piece rate,” or any other measurement are wages, even if the employee is a casual worker, day or contract laborer, part-time, or temporary worker.

Well Baby / Well Child Care Routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six.
Wellness Program A health management program which incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability which respond positively to lifestyle related interventions. See for more information.
The above Glossary was copied from Health Net’s Site
Material FactMore on UCR Article on MD’s site



The respondents contend that their fee schedules are pro competitive because they make it possible to provide consumers of health care with a uniquely desirable form of insurance coverage that could not otherwise exist. The features of the foundation-endorsed insurance plans that they stress are a choice of doctors, complete insurance coverage, and lower premiums. The first two characteristics, however, are hardly unique to these plans. Since only about 70% of *352 the doctors in the relevant market are members of either foundation, the guarantee of complete coverage only applies when an insured chooses a physician in that 70%. If he elects to go to a nonfoundation doctor, he may be required to pay a portion of the doctor’s fee. It is fair to presume, however, that at least 70% of the doctors in other markets charge no more than the “usual, customary, and reasonable” fee that typical insurers are willing to reimburse in full. [FN24] Thus, in Maricopa and Pima Counties as well as in most parts of the country, if an insured asks his doctor if the insurance coverage is complete, presumably in about 70% of the cases the doctor will say “Yes” and in about 30% of the cases he will say “No.”

Arizona v. Maricopa County Medical Soc. 102 S.Ct. 2466 U.S.Ariz.,1982. Jun 18, 1982 (Approx. 18 pages)What are customary and reasonable charges? Customary and reasonable charges, as determined by Health Net Life, are charges that fall within the common range of fees billed by a majority of physicians for a procedure in a given geographic region, or which are justified based on the complexity or the severity of treatment for a specific case.Health
Customary and Reasonable (C&R) (see negotiated rates) The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called “Usual, Customary and Reasonable” (UCR). See also Medicare RBRVS Usual, Customary and Reasonable

OPS offers many different policies to its subscribers, with varying terms. Under a majority of these policies, OPS offers a two-tier system covering health care costs. OPS conducts a survey of the fees for various services submitted to it by individual member physicians. Once the data has been compiled, the fees are referred to as the “usual, customary and reasonable” rates (UCR). OPS then determines the 90th percentile of such fees–that is, the rate at which 90 percent of the sample group charges the same or less. When a member physician treats an OPS subscriber, OPS pays the physician directly up to the 90th percentile rate. The member physician must accept the OPS payment as payment in full and may not bill the subscriber for any extra amount. Nonmembers, on the other hand, may bill subscribers at whatever rate they choose. A subscriber pays a nonmember’s bill and is then reimbursed by OPS, but generally at a rate no more than at the 60th percentile of the UCR. Nonmembers, unlike members, may bill subscribers for the balance of their fees. Appellants produced evidence that, on average, OPS members received from OPS 76 cents on the dollar billed, while OPS paid podiatrists only 50 cents on the dollar billed. OPS subscribers were free to seek treatment from members or nonmembers as they wished.

Hahn v. Oregon Physicians’ Service 860 F.2d 1501 C.A.9 (Or.),1988. Nov 04, 1988 (Approx. 6 pages)

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