Access: The availability of medical care to a patient which can be determined by location, transportation, type of medical services in the area.

Accident : An event that is not realized beforehand, unexpected, and unintended.

Accumulation: Period The period where the insured incurs eligible medical expenses to fulfill a deductible.

Actively-at-work: Actively-at-work A majority of group health insurance policies state that if an employee is not actively at work on the day the policy goes into effect, the coverage will not begin until the employee does return to work.

Actual Charge: Actual amount charged by a physician for rendering medical services.

Actuary: Accredited insurance mathematician who calculates premium rates, reserves, and dividends and who prepares statistical studies and reports.

Additional Drug Benefit List: Also known as drug maintenance list. Prescription drugs listed as commonly prescribed by physicians for patients' long-term use.

Administrative Services Only Agreement (ASO)): It is a contract between an insurer (or its subsidiary) and a group employer, eligible group, trustee, or other party, where the insurer provides certain administrative services. These may include actuarial support, plan design, processing, data recovery and analysis, benefits communication, financial advice, medical care conversions, data preparation for governmental reports, and stop-loss coverage.

Admissions/1,000: The number of hospital admissions for each 1,000 members of the health plan.

Admits: The number of admissions to a hospital which includes outpatient and inpatient facilities.

Adverse Selection: Trend of those who are poorer-than-average health risks to apply for, or maintain, insurance coverage.

Age Change: The date on which a person's age, for insurance purposes, changes. In most Life Insurance contracts this is the date midway between the insured's natural birth dates. Health insurers frequently use the age of the previous birth date for rate determinations. On the date of age change, a person's age may change to that of the last birth date, the nearer birth date, or the next birth date, depending upon the way in which the rating structure has been established by that particular insurer.

Age Limits: Ages below and above which an insurance company will not receive applications or renew policies.

Age/Sex Factor: Compares the age and sex risk of medical costs of one group relative to another.

Age/Sex Rates (ASR): Separate rates are determined for each grouping of age and sex categories. Also sometimes called table rates which is preferred over single and family rating because the rates and premiums automatically reflect changes in the age and sex content of the group.

Agent: Representative of the insurance company who is licensed by the state, solicits, negotiates insurance contracts and provides services to the policyholder for the insurer.

Ancillary Services: Health care support that patients receive from providers other than primary care doctors. Ancillary Benefits: Benefits for various hospital charges.

Average Length of Stay (ALOS): The total number of patient days divided by the number of admissions and discharges during a specified period of time. This gives the average number of days in the hospital for each person admitted.

Average Wholesale Price (AWP): Under the Medicare catastrophic coverage act, payment for prescription drugs is limited to the lowest of the pharmacy's actual charge, the sum of the AWP for the drug plus an administrative allowance, or effective 1992, the 90th percentile of pharmacy charges.

Base Capitation: Total amount which covers the cost of health care per person, less any mental health or substance abuse services, pharmacy, and administrative charges.

Basic Hospital Expense Insurance: Hospital coverage providing benefits for room, board and miscellaneous expenses for a specified number of days.

Benefit Package: A description of what services the insurer or health plan offers to those covered under the terms of a health insurance contract.

Benefit Period: Is a period during which a Medicare insured is eligible for Part A benefits, which is for 90 days and begins the day the patient is admitted to a hospital and ends when the beneficiary has not been hospitalized for a period of 60 consecutive days.

Birthday Rule: A method of deciding which parent's medical coverage will be primary for dependent children. The parent whose birthday comes earliest in the year will be considered as having the primary plan.

Carrier: A commercial insurer contracted by the Department of Health and Human Services to execute Part B claims payments.

Carry Over Provision: In major medical policies, allowing an insured who has submitted no claims during the year to apply any medical expenses incurred in the last three months of the year toward the new calendar year's deductible.

Case Management: The assessment of a person's long term care needs and the appropriate recommendations for care, monitoring and follow-up as to the extent and quality of services to be provided.

Case Manager: A person, who is an usually an experienced professional, coordinates the services necessary under the case management approach.

Certificate of Insurance: Document that briefs the provisions and benefits of a specific insurance contract.

Chemical Equivalents: Drugs that contain identical amounts of the same elements.

Closed Panel: A situation where covered insured must select one primary care physician. That physician is the only one allowed to refer the patient to other health care providers within the plan.

Coinsurance: The amount you are required to pay for medical care in a fee-for-service plan or preferred provider organization (PPO) after you have met your deductible. It is usually expressed as a percentage of billed charges. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.

Commercial Policy: In Health Insurance, this term originally applied to policy forms intended for sale to individuals in commerce, as contrasted with industrial workers. Currently the term is loosely used to mean all policies that do not guarantee renewability.

Community Rating: Under this rating system, the charge for insurance to all insured depends on the medical and hospital costs in the community or area to be covered. Individual characteristics of the insured are not considered at all.

Composite Rate: Regardless of the status as single or members of a family, there is one rate for all members of the group.

Concurrent Review: A case management technique which allows insurers to monitor an insured individuals hospital stay and to know in advance if there are any changes in the expected period of confinement and the planned release date.

Conditionally Renewable: A contract that provides that the insured may renew it to a stated date or an advanced age, subject to the right of the insurer to decline renewal only under conditions stated in the contract.

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986: Legislation providing for a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued for up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may be continued for up to 36 months in nearly all other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.

Continuation: Allows terminated employees to continue their group health insurance coverage under certain conditions.

Contract Year: Period which runs from the effective date to the expiration date of the contract.

Conversion Privilege: Right given to an insured person under a group insurance contract to change coverage. The conditions under which changes can be made are defined in the master policy.

Co-payment: Another way of sharing medical costs. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance company pays the rest.

Cost Contract: The agreement between a provider and the Health Care Financing Administration to provide health services to covered persons based on reasonable costs.

Cost Sharing: A situation where covered persons pay a portion of the health costs such as deductibles, coinsurance, or co-payment amounts.

Covered Expenses: Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.

Covered Individual: An individual who pays premiums into the contract for the benefits provided meeting the eligibility.

Date of Service: The date that the health service was provided. Deductible: A specified dollar amount paid by the covered individual in each deductible accumulation period before payment of benefits be made by the insurance company.

Deductible Carryover Credit: During the last three months of a calendar year, charges incurred for health services can be used to satisfy the deductible for the following calendar year. These credits may be applied whether or not the prior calendar year's deductible had been met.

Dependent Coverage: Insurance coverage on the head of a family which is extended to his or her dependents, including only the lawful wife and unmarried children who are not yet working on a full-time basis and who may be step, foster, adopted, as well as natural. There are certain age restrictions on children.

Drug Utilization Review (DUR): A method evaluating and re-examining the use of drugs in order to determine the appropriateness of the drug therapy.

Eligibility Date: The date when the insured person is entitled for benefits. Eligibility Period: The time following the eligibility date which is usually 31 days during which a member of a group can apply for insurance without proof of insurability.

Eligible Dependent: A dependent of an insured person entitled for insurance coverage in accordance with the rules set forth in the contract. Eligible Employee: An employee entitled for insurance coverage based on the requirements laid down in the group contract.

Eligible Expenses: The expenses indicated in the contract as being eligible for coverage. This may include specified health services fees or "customary and reasonable charges." Eligible Person: Is similar to the rules for eligible employee apart from the fact that it is a contract for people who are not employees of a specified employer. Examples- members of an association, union, etc.

Employee Certificate of Insurance: The employee's evidence of participation in a group insurance plan, consisting of a brief summary of plan benefits. The employee is provided with the insurance certificate and not the actual insurance policy.

Employee Contribution: The premium cost which is borne by the employee's.

Employer Contribution: The cost borne by the employer. Enrollee : An entitled individual registered in a health plan not including an eligible.

Enrollment Card: The document signed by an entitled person signifying his desire of participation in a group insurance plan. The card sanctions an employer to deduct contributions from an employee's pay. If life and accidental death and dismemberment coverage are included, the card usually includes the beneficiary's name and relationship.

Enrollment Period : The span of time an employee has to sign up for a contributory health plan.

Examination: The medical examination that is done of an applicant for Life or Health insurance.

Exclusions: Specific circumstances for which the policy will not provide benefits.

Extended Coverage: In certain Health policies, usually Group, benefits are provided to the insured person for specified losses sustained after the end of coverage, such as maternity expenses incurred for a pregnancy in progress at the time of the termination of the coverage.

Extension of Benefits : A condition in the insurance policy which enables coverage to exist beyond the policy expiry date in the case of employees who are not actively at work or dependents who are hospitalized on that date. The extended coverage is stretched till the the time the employee returns to work or the dependent is released from the hospital.

Fee-for-Service: A system of payment for health care where the provider is paid for each service delivered rather than negotiated earlier for each patient. Fee Maximum: The maximum amount accessible to the provider for specific health care services laid down in the contract.

Fee Schedule : A program determining he maximum fees for providers who are on a fee-for-service basis.

Field Underwriting: The initial scrutiny done by the sales team in the field, of prospective buyers of health insurance, which also include quoting of premium rates.

Flat Maternity Benefit: A stipulated benefit in a Hospital Reimbursement policy that is paid for maternity confinement, regardless of the actual cost of the confinement.

Flexible Benefit Plan : A program where employees can alter their benefits to meet their own specific needs.

Formulary: Listed pharmaceutical products that are to be used by a managed care plan's network physicians. Formularies are based on evaluations of the efficacy, safety, and cost-effectiveness of drugs.

Jet screening: The process of evaluating the applications for insurance according strict criteria mentioned underneath.

Joint and survivor annuity: An annuity under which a series of payments is made to two or more annuitants. The annuity payments continues until the death of both or all of the annuitants. This is also known as a joint and last survivorship annuity. joint and survivorship option: A life insurance settlement wherein payments will be made to two or more payees. These payments will continue until both or all the named payees are dead.

Joint credit life insurance: A procedure wherein the full benefit amount is paid to a lender upon the death of any of the cosigners of a loan.

Joint life and last survivor option (JL&S): In Canada, pension benefits are provided to the spouse of a retired plan participant after the death of the participant. The survivor's benefits, is not as large as the original benefits, and continue till the death of the spouse. An almost similar provision, called a qualified joint and survivor (QJ&S) annuity, is required in the United States for qualified pension plans.

Joint whole life insurance policy: An insurance policy that covers two lives and that provides for payment of the proceeds at the time of of the first insured. juvenile insurance policy: A life insurance policy purchased to cover the life of a child by an adult.

Key-person insurance: Life insurance purchased by a company for the life of a person (usually an employee) whose continued participation in the business is necessary to the firm's success and whose death or disability would cause financial loss to the company. Lapse Termination of coverage due to nonpayment of premium within a specified time period. Late-remittance offer A means of supporting and restoring lapsed insurance policies. A late-remittance offer specifies that the company will accept an overdue premium after the grace period ends and will restore the policy without any reinstatement application or evidence of insurability from the policy owner. This is also known as a late-payment offer.

Level premium annuity: A deferred annuity for which the purchaser of the annuity pays equal premium amounts at regular intervals, like monthly or annually, until the scheduled date when the benefit payments will begin.

Level premiums: Same premiums that are being paid each year as long as the life insurance policy is in force.

Level term insurance: A type of insurance that provides a death benefit. Premiums for level term insurance policies usually remain the same throughout each term of coverage.

Liabilities: For an insurance company, liabilities include the amounts owed to creditors and the expected claims of its policy owners and their beneficiaries. A company's debts and future obligations.

Licensed broker: An insurance salesperson who is not with any insurance company through an agency ,and who is usually an agent of the client and not of the insurer. Such insurance salesperson are known as pure brokers.

Lifetime Maximum : The maximum amount of benefit that a member gets during his or her lifetime. All benefits provided are subject to this maximum unless stated as unlimited.

Short-Term Disability: An injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual's full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.

Triple-Option: Insurance plans that offer three options from which an individual may choose. Usually, the three options are: traditional indemnity, an HMO, and a PPO.

Waiting Period: Period of time when one is not covered by insurance for a particular problem.