Insurance definitions & glossary

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 week.com/ama-assn.org/

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 today.com California DMHC – Press 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. .leginfo.legislature.ca.gov/

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 americanbar.org/l

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.

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.

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

See also: Generic Drug.

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.

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

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

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.

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.

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.

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.

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.

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

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

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.

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

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

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

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.

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.”

www.steveshorr.com/

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)