The monthly premium is usually lower, but you pay more of the healthcare costs when you seek care before your deductible is met. Limited Policies - health insurance coverage for a certain ailment, such as cancer. Documents exposed by various committee workgroups. Tier 1 usually covers generic medications, making this the lowest-cost tier. With this type of account, you (along with your employer, in some cases) can make contributions up to a maximum of $2650 in 2018 (the cap on contributions changes every year). Alien Company - an insurance company formed according to the laws of a foreign country. These policies may be renewable for multiple periods. Builders' Risk Policies - typically written on a reporting or completed value form, this coverage insures against loss to buildings in the course of construction. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered . Foreign Investment - an investment in a foreign jurisdiction, or an investment in a person, real estate or asset domiciled in a foreign jurisdiction. This statement is used by the NAIC, and by State Insurance Commissioners to regulate an insurance company according to reserve requirements, assets, and other liabilities. These individuals work on behalf of the customer and are not restricted to selling policies for a specific company but commissions are paid by the company with which the sale was made. Personal Flood - separate flood insurance policy sold for personal, family or household purposes. Reserve - A portion of the premium retained to pay future claims. Also include short-term care policies that provide coverage for less than one year for medical and other services provided in a setting other than an acute care unit of the hospital. Medical & Hospital Expenses (Benefits or Claims) - total expenditures for health care services paid to or on behalf of members. The definitions in this glossary are developed by the NAIC Research and Actuarial Department staff based on various insurance references. . Centers for Medicare & Medicaid Services (CMS) - U.S. governmental agency responsible for the licensing of federally qualified HMOs. If you have employer-sponsored health insurance, your employer might pay a portion of your premium each month. Account Number This is a number assigned to identify each episode of care. anything until you've met your $1000 deductible for covered health care services subject to the deductible. Declarations - policy statements regarding the applicant and property covered such as demographic and occupational information, property specifications and expected mileage per year . Dental Insurance - policies providing only dental treatment benefits such as routine dental examinations, preventive dental work, and dental procedures needed to treat tooth decay and diseases of the teeth and jaw. Original Medicare has two parts: Part A and Part B. No waiting period for preventive care: 10% of score. Having a problem with an insurance company or agent? Deductible - The annual amount of money that you must pay out of pocket for medical expenses before your insurance kicks in and starts to make payments. Long-Term Care - policies that provide coverage for not less than one year for diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services provided in a setting other than an acute care unit of a hospital, including policies that provide benefits for cognitive impairment or loss of functional capacity. "Dual Interest" includes insurance commonly referred to as "Limited Dual Interest.". Underlying Interest - the asset(s), liability(ies) or other interest(s) underlying a derivative instrument, including, but not limited to, any one or more securities, currencies, rates indices, commodities, derivative instruments, or other financial market instruments. Federal Flood Insurance - coverage for qualifying residents and businesses in flood prone regions through the National Flood Insurance Act, a federally subsidized flood insurance program enacted in 1968. Contractual Liability - liability coverage of an insured who has assumed the legal liability of another party by written or oral contract. Mortgage Guaranty - insurance that indemnifies a lender for loss upon foreclosure if a borrower fails to meet required mortgage payments. Benefits (Medical & Hospital Expenses) - total expenditures for health care services paid to or on behalf of a member. Here you will find some key insurance terms and definitions. Basic care payout level . In accordance with the generally accepted standards of medical practice, Clinically appropriate in terms of type, frequency, extent, site and duration, Considered effective for the patients illness, injury or disease, Not primarily for the convenience of the patient or doctor. Authorized Reinsurance - reinsurance placed with a reinsurer who is licensed or otherwise allowed to conduct reinsurance within a state. The formula reflects market value adjustments. (In Life and Health) this document would be called an "Actuarial Memorandum.". Part B is medical insurance and covers doctor visits, outpatient care, medical supplies, and some preventive services. Types of coverage include student accident, sports accident, travel accident, blanket accident, specific accident or accidental death and dismemberment (AD&D). Environmental Impairment Liability (EIL) - coverage for negligence or omission resulting in pollution or environmental contamination. Published: Dec 19, 2022, 7:00am Editorial Note: We earn a commission from partner links on Forbes Advisor. Risk Retention Group - group-owned insurer organized for the purpose of assuming and spreading the liability risks to its members. Confusion About Health Insurance Terms More than three-quarters (77%) misunderstand coinsurance. For 2022 1, the out-of-pocket limit for a health insurance marketplace plan is $8,700 for individual coverage and $17,400 for a family plan. Limited Benefit - policies that provide coverage for vision, prescription drug, and/or any other single service plan or program. Individual Annuities- Deferred Non-Variable - an annuity contract that provides an accumulation based on funds that accumulate based on a guaranteed crediting interest rate or additional interest rate. Excess and Umbrella Liability - liability coverage of an insured above a specific amount set forth in a basic policy issued by the primary insurer; or a self insurer for losses over a stated amount; or an insured or self insurer for known or unknown gaps in basic coverages or self insured retentions. Statement Value - the Statutory Accounting Principle book value reduced by any valuation allowance and non-admitted adjustment applied to an individual investment or a similar group of investments, e.g., bonds, mortgage loans, common stock. Derivative - securities priced according to the value of other financial instruments such as commodity prices, interest rates, stock market prices, foreign or exchange rates. Copay - a cost sharing mechanism in group insurance plans where the insured pays a specified dollar amount of incurred medical expenses and the insurer pays the remainder. A flexible spending account (FSA) is a special type of account used to pay for health expenses. Hospital Indemnity Coverage - coverage that provides a pre-determined, fixed benefit or daily indemnity for contingencies based on a stay at a hospital or intensive care facility. Commercial Package Policy - provides a broad package of property and liability coverages for commercial ventures other than those provided insurance through a business owners policy. The interval may vary, however the annuity payouts must begin within 13 months. Benefits include (i) property of the insured, which has been directly damaged by the accident; (ii) costs of temporary repairs and expediting expenses; and (iii) liability for damage to the property of others. If youve ever been confused by a health insurance term such as coinsurance, deductible, or premium to name a few you are not alone. Short-term Health Insurance. May include losses that have been reported to the reporting entity but have not yet been entered into the claims system or bulk provisions. Nuclear Energy Liability - coverage for bodily injury and property damage liability resulting from the nuclear energy material (whether or not radioactive) on the insured business's premises or in transit. Advance Premiums - occur when a policy has been processed, and the premium has been paid prior to the effective date. Annuities Immediate Non-variable - an annuity contract that provides for the fixed payment of the annuity at the end of the first interval of payment after purchase. Stop Loss/Excess Loss - individual or group policies providing coverage to a health plan, a self-insured employer plan, or a medical provider providing coverage to insure against the risk that any one claim or an entire plan's losses will exceed a specified dollar amount. Statement Type - refers to the primary business type under which the company files its annual and quarterly statement, such as Life, Property, Health, Fraternal, Title. The U.S. Food and Drug Administration (FDA) rates these to be as safe and effective as brand-name medications. Joint-Life Annuity - an annuity contract that ceases upon the death of the first of two or more annuitants. Fraternal Insurance - a form of group coverage or disability insurance available to members of a fraternal organization. Access forms and tools to file expense reports, review grant and zone scholarship balances, and travel guidelines. Qualified Actuary - a person who meets the basic education, experience and continuing education requirements (these differ by line of business) of the Specific Qualification Standard for Statements of Actuarial Opinion, NAIC Property and Casualty Annual Statement, as set forth in the Qualification Standards for Actuaries Issuing Statements of Actuarial Opinion in the United States, promulgated by the American Academy of Actuaries, and is in good standing of the American Academy of Actuaries who has been approved as qualified for signing casualty loss reserve opinions by the Casualty Practice Council of the American Academy of Actuaries. Other Liability - coverage protecting the insured against legal liability resulting from negligence, carelessness, or a failure to act resulting in property damage or personal injury to others. Burglary and Theft - coverage for property taken or destroyed by breaking and entering the insured's premises, burglary or theft, forgery or counterfeiting, fraud, kidnap and ransom, and off-premises exposure. Personal Injury Liability - liability coverage for those who have been discriminated against, falsely arrested, illegally detained, libeled, maliciously prosecuted, slandered, suffered from identity theft, mental anguish or alienation of affections, or have had their right of privacy violated. We provide tools and resources to help regulators set standards and best practices, provide regulatory support functions, and educate on U.S. state-based insurance regulation. Statutory rules also govern how insurers should establish reserves for invested assets and claims and the conditions under which they can claim credit for reinsurance ceded. Insurer - an insurer or reinsurer authorized to write property and/or casualty insurance under the laws of any state. Medical Only - line of business that provides medical only benefits without hospital coverage. No Fault is defined by the state concerned. Medical Professional Liability is also known as Medical Malpractice. The account is opened through the HSA provider chosen by your employer. Glossary of Health Insurance Terms | Blue Cross and Blue Shield of Texas Glossary of Health Care Terms Health insurance is full of terms you may not know. All Marketplace plans cover prescription drugs. By choosing I Agree, you understand and agree to JDRFs Privacy Policy. Group Annuities Immediate Variable - an annuity contract that provides for the first payment of the annuity at the end of the fixed interval of payment after purchase. Accidental Death & Dismemberment - an insurance contract that pays a stated benefit in the event of death and/or dismemberment caused by accident or specified kinds of accidents. For availability, costs and complete details of coverage, contact a licensed agent or Cigna Healthcare sales representative. The amount varies with the value of equities (separate account) purchased as investments by the insurance companies. Vision - limited benefit expense policies. An example is a tenant who, while occupying another party's property, through negligence causes fire damage to the property. Covered Lives - The total number of lives insured, including dependents, under individual policies and group certificates. Effective Date - date at which an insurance policy goes into force. Clinical studies, or trials, are part of the process by which new therapies receive approval by the FDA. OKLAHOMA CITY, June 8, 2023 /PRNewswire/ -- Aetna Better Health of Oklahoma has been selected to serve Oklahoma Medicaid beneficiaries by the Oklahoma Health Care . A preventive drug list is a list of medications your health insurance plan classifies as not being subject to your deductible. Deductible - Portion of the insured loss (in dollars) paid by the policy holder. Because health insurance contracts last for one year, your monthly premium multiplied by 12 months is the minimum amount youll spend in a given year. The definitions in this glossary are developed by the NAIC Research and Actuarial Department staff based on various insurance references. Be sure to check your plan for those specific details before scheduling any appointments. The U.S. Department of Health and Human Services has developed a glossary for common terms related to health insurance, such as "deductible", "co-payments" and "out-of-pocket limits." Paying for Health Care or Health Insurance Your PCP is at the center of your medical care, getting to know you, helping coordinate all your care, and providing referrals to see in-network specialists. Corrective Order - commissioner's directive of action to be completed by an insurer. Higher tiers cover preferred and non-preferred brand-name medications at a higher cost to you. Professional Errors and Omissions Liability - coverage available to pay for liability arising out of the performance of professional or business related duties, with coverage being tailored to the needs of the specific profession. For example, if Jane pays Her plan pays your deductible is $1000, 100% 0% your plan won't pay (See page 4 for a detailed example.) A co-payment is a flat amount, found in your policy documents, that you are required to pay for certain medical services or medications. This is any private health insurance plan held by a Medicare or commercial beneficiary, including Medigap policies or post-retirement benefits. Key Points. Coinsurance has become increasingly more common in recent years. Premium A premium is the amount of money you will pay to carry your health insurance plan. The policy does not include coverage provided under comprehensive/major medical policies, Medicare Advantage, or for accelerated heath benefit-type products. Insurance Regulatory Information System (IRIS) - a baseline solvency screening system for the National Association of Insurance Commissioners (NAIC) and state insurance regulators established in the mid-1970s. Ambulatory services are often referred to as "outpatient" services. Insurance usually does not cover costs related to investigational treatments. 6/27/2015. Contingency Reserves - required by some jurisdictions as a hedge against adverse experience from operations, particularly adverse claim experience. Encourages participation by private insurers through a flood insurance pool . Group Annuities Immediate Non-Variable and Variable - an annuity contract that provides an accumulation based on both (1) funds that accumulate based on a guaranteed crediting interest rates or additional interest rate applied to designated considerations, and (2) funds where the accumulation vary in accordance with the rate of return of the underlying investment portfolio selected by the policyholder. Did we miss something? It's important to understand your costs and key health insurance terms, so you'll know what services your plan will pay for and how much each visit or medicine will cost. Standard Risk - a person who, according to a company's underwriting standards, is considered a normal risk and insurable at standard rates. Par Value - the nominal or face value of a stock or bond. Providers set charges for the various medications, items and services they provide, in the same way that a retailer sets prices on items sold in its store. All insurance policies and group benefit plans contain exclusions and limitations. Rebate - a refund of part or all of a premium payment. Examples of items covered are pension plans, group life insurance, group health insurance, group disability income insurance, and accidental death and dismemberment. Provides benefits for eye care and eye care accessories. Gross Paid-in and Contributed Surplus - amount of capital received in excess of the par value of the stock issued. Subscribe to our monthly newsletter today. "Cause of Loss". Generic Medication (also known as generic drug). Whole Life Insurance - life insurance that may be kept in force for the duration of a person's life and pays a benefit upon the person's death. Admission - hospital inpatient care for any medical condition. Access forms, tools, and resources for individuals and organizations to file forms, improve efficiency, and remain compliant. Broker - an individual who receives commissions from the sale and service of insurance policies. Morbidity Risk - the potential for a person to experience illness, injury, or other physical or psychological impairment, whether temporary or permanent. Health Insurance 101: Defining Key Terminology Healthcare Expertise Whole Person Health If you've ever been confused by a health insurance term such as coinsurance, deductible, or premium - to name a few - you are not alone. Health Maintenance Organization (HMO) - a medical group plan that provides physician, hospital, and clinical services to participating members in exchange for a periodic flat fee. Personal Property - single interest or dual interest credit insurance (where collateral is not a motor vehicle, mobile home, or real estate) that covers perils to goods purchased or used as collateral and that concerns a creditor's interest in the purchased goods or pledged collateral either in whole or in part; or covers perils to goods purchased in connection with an open-end credit transaction. Flood - coverage protecting the insured against loss or damage to real or personal property from flood. Insured - party(ies) covered by an insurance policy. The beneficiary may use providers outside the provider network. Coordination of Benefits (COB) - provision to eliminate over insurance and establish a prompt and orderly claims payment system when a person is covered by more than one group insurance and/or group service plan. For example not taking proper care to protect insured property because the insured knows the insurance company will replace it if it is damaged or stolen. Understanding the meanings of these concepts will help equip you to better address any barriers and make smart decisions that will benefit you and your family. Living benefits rider - a rider attached to a life insurance policy providing long term care for the terminally ill. Lloyd's of London - association offering membership in various syndicates of wealthy individuals organized for the purpose of writing insurance for a particular hazard. Ocean Marine - coverage for ocean and inland water transportation exposures; goods or cargoes; ships or hulls; earnings; and liability. Doctors in Germany. The most common forms of non-proportional reinsurance are stop loss and catastrophe. Glossary of Insurance Terms This page provides a glossary of insurance terms and definitions that are commonly used in the insurance business. Risk Retention Act - a 1986 federal statute amending portions of the Product Liability Risk Retention Act of 1981 and enacted to make organization of Risk Retention Groups and Purchasing Groups more efficient. Adjuster - a person who investigates claims and recommends settlement options based on estimates of damage and insurance policies held. Warranty insurance generally protects consumers from financial loss caused by the seller's failure to rectify or compensate for defective or incomplete work and cost of parts and labor necessary to restore a product's usefulness. Accident Only or AD&D - policies providing coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by or necessitated as a result of accident or specified kinds of accidents. These are a liability to the company and not included in written premium or the unearned premium reserve. Designates must also have at least three years experience in the insurance business or related field. Change in Valuation Basis - a change in the interest rate, mortality assumption or reserving method or other factors affecting the reserve computation of policies in force. Dwelling Property/Personal Liability - a special form of package policy composed of dwelling fire and/or allied lines, and personal liability insurance. Prescription drug coverage. Supplemental insurance policies can be purchased in addition to your primary health insurance. Soft Market - a buyer's market characterized by abundant supply of insurance driving premiums down. For example, you may have a co-pay of $30 for a doctors visit, $20 for one kind of prescription, and $50 for another type of prescription. Superfund - federal act mandating retroactive liability for environmental pollution where responsible party maintains accountability for environmental clean-up regardless of length of time since polluting event occurred. health insurance - Germany / Target companies in 'Munich, Nuremberg and Bavaria' that specialise in the 'health insurance' field Wegovy, a higher dose of the same drug as Ozempic, is approved for weight loss. Representatives from diverse groups who provide varied perspectives on insurance regulatory issues. Fees Payable - fees incurred but not yet paid. The insurer is required to renew the policy regardless of the health of the insured subject to policy conditions. Joint Underwriting Association (JUA) - a loss-sharing mechanism combining several insurance companies to provide extra capacity due to type or size of exposure. Excluded are losses resulting from fire, explosion, flood or tidal wave following the covered event. Medicare offers a variety ofenrollment periods, each governed by specific requirements. Public Adjuster - independent claims adjuster representing policyholders instead of insurance companies. A health maintenance organization (HMO) health plan gives you a local network of doctors, hospitals, and other health care professionals and facilities to choose from. Title Insurance - coverage that guarantees the validity of a title to real and personal property. Retrocession - the portion of risk that a reinsurance company cedes or amount of insurance the company chooses not to retain. Question How have out-of-pocket (OOP) costs for naloxone in the US changed between 2010 and 2018 overall and by drug brand and payer?. Compensation for the injured party is equal to the difference between the losses incurred and the liability covered by the motorist at fault.
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