Affiliation Period.  With respect to HMOs, this is the time after an enrollment a carrier may require a new policy holder to wait prior to the coverage going into effect.  It is illegal for carriers to charge premiums during the ýwaiting periodý.  Note: HMOs which impose affiliation periods may not exclude coverage of pre-existing conditions.  

Cap   Maximum amount an insured can be billed for medical costs within any given year.  A cap tabulates such out-of-pocket expenses as annual deductible and coinsurance payments when ascertaining the total pay out amount by a policy holder.

Certificate of Creditable Coverage  Carrier provides policy holders with written documents verifying an individualýs level of coverage under a particular plan.  Typically, these types of certificates are provided when an individual departs from a plan.

Childrenýs Medical Security Insurance Plan.  For children under the age of 19 who are ineligible for Medicaid and who do not have health insurance or limited amounts, the Childrenýs Medical Security Insurance Plan provides them with subsidized insurance.

COBRA.  An active federal law since 1986, COBRA which means Consolidated Omnibus Budget Reconciliation Act, makes it possible for an individual and their dependents to remained covered under the employerýs group health plan after leaving a position.

COBRA Continuation Coverage is available for those who worked for companies with 20 or more employees are were fired, quit, retired or relegated to working reduced hours.  Dependents of employees, encompassing survivors, divorcees and separated spouses, as well as, dependent children, are also entitled to coverage under COBRAýs Continuation Coverage which generally lasts 18 months, 36 months for dependents who qualify.

Coinsurance After the annual deductible has been met, the remaining amount the policy holder must pay for medical |health charges.  The amount is derived as a percentage of that which the insurance company will not pay.  For example 50/50 is an expression meaning the insurer will pay 50%, leaving the policy holder with a remaining balance of 50%.

Continuous Coverage (Group Health Plans)  In order to qualify for group health insurance plans, the requirement (so long as one has not been deemed federally eligible) is that oneýs previous coverage must have been on-going.  Here, the term of continuous is defined as non-interrupted for a period of 63 or more consecutive days.  Note: For the purpose of determining whether coverage has been continuous, employer waiting periods and HMO affiliation periods are not calculated into the equation.

Continuous Coverage (Individual Health Plans).  In order to qualify for individual health insurance plans, the requirement (so long as one has not been deemed federally eligible) is that oneýs previous coverage must have been on-going.  Here the term of continuous is defined as non-interrupted for a period of 30 or more days. 

Conversion   Within the Commonwealth of Virginia, individuals departing from a group health plan may be able to re-structure (convert) their former group coverage into an individual plan.  However, the converted coverage may not be identical to coverage under the group plan and may be more expensive.

Coordination of Benefits Process by which the benefits to which an individual with multiple plans is entitled are checked and balanced to eliminate duplications. The capped limited is that benefits under the combined plans can not exceed 100% of the claim.

Co-payment  Flat fee an insured is responsible for paying after medical services have been received or performed.  Generally, usage of co-payments is employed under managed care plans. Hence, a policy holder pays the initial $10 towards the overall costs for prescription drugs and the insurer pays the remaining amount.

Covered Expenses  Specific services and products an insurance company agrees to pay for as stipulated within the textual portion of an insurance plan.

Creditable Coverage (Group Health Plans). Term applied to all health insurance coverage provided under the following types of plan: group health plans; individual health plans; Medicare; Medicaid; CHAMPUS and TRICARE (coverage for military personnel, retirees, and dependents); Federal Employees Health Benefits Program; Indian Health Services; Peace Corps; and those within a state health insurance high risk pool.  Determinations to provide future coverage are often based upon an individualýs past experience with having creditable coverage.

Creditable Coverage (Individual Health Plans).  Term applied to all health insurance coverage provided under the following types of plans: individual or group policies that provide hospital, medical, major medical or surgical coverage.

Deductible  Annual amount paid by the policy holder for medical care costs expenses before the insurance carries will step in and assume responsibility over making payments.

Enrollment Period  Time span in which all employees and their dependents are eligible to enroll in an employerýs group health plan.  Typically, upon being hired, employers are asked to select their health benefits of preference. And, on annual basis, an enrollment period is held in employees who have not done so may sign-up or change previously selected benefits. 

Elimination Rider  Addendums to individual health insurance policies which may exclude coverage for a health condition, body part, or body system.  Some elimination riders can stay in effect throughout a personýs lifetime. Elimination riders may not be imposed if one is deemed federally eligible or, at the time of enrollment, the insurer neglected to have one fill-out a long form application and instead only required the submission of a simplified application.

Exclusions Pre-stated conditions or instances over which the policy will not extend coverage.

Family and Medical Leave Act (FMLA). Federal law that provides for a period of up to 12 weeks of job-protected leave for employees qualifying as needing to take time on account of: a serious illness, having or adopting a child, or caring for a family member.  As stated by the provisions of FMLA, oneýs coverage remains in force under their group health plan.

Federally Eligible.   Once an individual has accrued 18 months of continuous creditable coverage he/she reaches the status of becoming federally eligible.  In addition, one must also have used up any existing COBRA or state continuation coverage, not be eligible for Medicare or Medicaid, not have any other health insurance and must apply for individual health insurance within 63 days of separation from his/her prior source of creditable coverage.

Fee-for-Service  Healthcare payment option in which caregivers are paid per service provided to each patient versus a set amount per patient.

Formulary  Within a managed care plan, a physician drafted list of preferred pharmaceutical products called upon when they prescribe specific medications and treatments to patients.

Fully Insured Group Health Plan.  With the intention of making it available to employers, health insurance plans purchased by an employer.  Fully insured health plans are regulated by the Commonwealth of Virginia.

Generic Drug  Prescription medication for which the composition is identical to that of a brand name medication.  Generic drugs may only be produced after the brand name counterpartýs initial patent (typically seven years) has expired.

Genetic Information.  Detailed history of family and membersý correlative DNA taken and employed for the purpose of detecting hereditary health conditions. Note:  It is not legal for health plans to use knowledge of pre-existing conditions and possibly deny coverage based upon such information without a formal diagnosis  made by a certified health professional.

Group Health Plan     Generally sponsored by an employer, union or particular professional association, a health insurance plan must cover a minimum of two persons.

Guaranteed Issue  Regardless of the status of oneýs health, age, gender or other pertinent, possibly discriminatory factors, regulation stipulating that health plans must make enrollment open to everyone. Within the Commonwealth of Virginia, all health plans sold to small employers (having between two and 50 employees) are guaranteed issue.  

Guaranteed Renewability  A specialized feature in certain health plans indicative of the fact the coverage may not be cancelled on account of illness that arises after enrollment.  

Health Insurance or Health Plan.  A broad term used to encompass all benefits that address medical care provided via either a hospital or doctor for which individualýs either have protection under insurance or are reimbursed for the outlay of moneys.

The term excludes coverage  limited to accident or disability insurance, workersý compensation insurance, liability insurance (including automobile insurance) for medical expenses, or reimbursements | coverage for on-site medical clinics. In addition, limited dental or vision benefits do not qualify as health insurance so long as they are covered under a separate policy.

Health Maintenance Organization (HMO) Term refers to the policy under which individualsý pay a pre-set monthly premium and then policy provides in full for such health | medical services as:  doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy sessions. Note: Policy holders must see doctors and hospitals within their HMOýs network in order to qualify for full coverage.

Health Plan Year   Term applies to the complete calendar period during which oneýs coverage under his/ her plan remains in effect. Note: Health plan years may or may not run concurrently with traditional calendar years.

Health Status    Encompassing both oneýs physical and mental state, this terms makes reference to oneýs overall medical condition inclusive of: the timely receipt of care, medical history, genetic | hereditary lineage, claims experiences, matters of disability and insurance coverage.

The Health Insurance Portability and Accountability Act (HIPAA)  Sometimes referred to as Kassebaum-Kennedy, an homage to the two senators responsible for spearheadeding the bill, its purpose has been to help people purchase and retain health insurance, even in the instances of serious health problems. As states have modified and expanded upon the billýs original provisions, protections to consumers now vary from state to state.

Indemnity Plan Form of traditional health insurance in which the insurer typically covers a pre-specified percentage of any medical | health costs incurred so long as the insured has paid his/ her annual deductible

Individual Health Plan  Policies designed for persons not part of a group health plan offered through an employer. The Commonwealth of Virginia regulates all individual health plans.

Insured  Person to whom coverage is provided under a health insurance policy. The term policy holder also applies.

Kassebaum-Kennedy  SA reference to the two State Senators who drafted The Health Insurance Portability and Accountability Act (HIPAA) (see aforementioned listing.)

Large Group Health Plan  Plans designed for companies | businesses with more than 50 employees.

Late Enrollment  Rather than at the scheduled enrollment time, enrollment at a subsequent time /day.  Note: Late enrollees may be subject to longer pre-existing exclusionary periods.

Look Back   Immediately after enrolling in a health plan, the maximum time frame in which an insured may be required to undergo a medically examination for the purpose of obtaining evidence of a pre-existing condition.

Maximum Out-of-Pocket  Highest annual amount an individual can be required to for both deductibles and coinsurance.  This is a pre-set amount decided a the onset of enrollment by the insurance company.  Note: This amount does not factor in regular premiums.

Managed Care  Structured healthcare system designed to manage health and medical costs incurred by policy holders, as well as, monitor the use and quality of healthcare provisions.  Note: Managed care systems encompass all HMO and PPO plans.

Medicaid  Within the Commonwealth of Virginia, program established to provide comprehensive health insurance coverage and additional health | medical assistance to qualifying low-income Virginia residents.  Note: Eligibility levels and benefits coverage vary from state to state.

Nondiscrimination.  Legal requirement stating that group health plans may not turn away anyone based upon oneýs health status. Hence, under a group plan, based oneýs health status, his/her coverage may not be denied or restricted, nor the basis upon which higher premiums are charged. However, so long as they are unrelated to health issues, group health plans do have the right to limit coverage based upon other factors i.e. part-time employment status.

Point-of-Service (POS)  Managed-care plans which combine select features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs).  The distinction between most POS plans is they offer the insured the option of whether to see a doctor within the planýs network and pay a pre-set copay amount or see his/her doctor of choice and pay an annual deductible, in addition to, a coninsurance fee.

Pre-existing Condition (Group Health Plans) A physical or mental condition for which medical advice, diagnosis, care, and | or treatment was recommended or received within the 6-month period within the immediate six month period following enrolment in a health plan.  Pregnancy does not constitute as a pre-existing condition.  And without proper diagnosis, genetic information pertaining to the likelihood that a condition or disease will develop also does not constitute as a pre-existing condition.

Pre-existing Condition (Individual Health Plans).  Any condition for which medical advice, diagnosis, care, or treatment was recommended or received, or any condition which, in the insurerýs judgment, most people would have sought care or treatment.  Plans can look back 12 months to see if you received care or should have received care.  Pregnancy can be counted as a pre-existing condition, but genetic information cannot be counted as a pre-existing condition in the absence of a diagnosis.  Newborns, newly adopted children, and children placed for adoption covered within 30 days cannot be subject to pre-existing condition exclusions.

Pre-existing Condition Exclusion Period  Established period of time during which a health plan does not cover health | medical care received in conjunction with any condition determined to be pre-existing.

Premium  Pre-set payment amounts made by a policy holder to an insurance company for the purpose of sustaining health | medical coverage and benefits as stipulated under his/ her plan.

Primary Care Physician or Doctor   Regardless of whether this is a family physician, internist or gynecologist, this person should be the first point of contact for issues relating to healthcare.  Generally speaking, primary care physicians know a patientýs history and are able to effectively make diagnoses based upon such insight. IN addition to monitoring medical situations and treating minor ailments, they may also be able to prescribe medications and make referrals to specialists, as needed.

Provider  Term encompasses all certified medical professionals i.e. doctors, nurses, dentists, as well as, institutions, i.e. hospitals and clinics which provide health-related treatment and care.

Prudent Person Rule.   Within the Commonwealth of Virginia, this term which specifically address pre-existing conditions, only applies to individual health plans. Under the prudent person rule, insurers are permitted to qualify as pre-existing any condition which, from the insurerýs perspective, ý the majority of people would have treated prior to enrolling in an individual health plan.

Self-Insured Group Health Plans.  Employer established plans in which they set aside funds so that they may pay their employeesý health claims.  As these plans are usually run by outside insurance carriers, they often resemble fully insured plans.  However, as an employeesý creditworthiness with healthcare providers is on the line, employers must disclose whether an outside insurer is merely administering the plan as opposed to also funding it.  

Short Term Health Insurance Plan  Sometimes called temporary health insurance, short-term plans offer general coverage and are only designed to provide benefits for gap periods in which one has no health insurance.

Small Group Health Plans Plans designed for companies | businesses with between two and 50 employees.

Special Enrollment Period.  A time, triggered by certain specific events, during which you and your dependents must be permitted to sign up for coverage under a group health plan. Employers and group health insurers must make such a period available to employees and their dependents when their family status changes or when their health insurance status changes.  Special enrollment periods must last at least 30 days.  Enrollment in a health plan during a special enrollment period is not considered late enrollment.  See also Late Enrollment.

State Continuation Coverage. In Virginia, if you are in a fully insured group health plan sponsored by an employer and meet other requirements, you might be offered the opportunity to purchase a continuation policy when you are no longer eligible for the employerýs plan.

Supplemental Security Income (SSI).  A program providing cash benefits to certain very low income disabled and elderly individuals.  When you qualify for SSI, you generally also qualify for Medicaid.  In addition, Medicaid coverage often continues for a limited time if your income increases so that you no longer qualify for SSI.

Temporary Assistance for Needy Families (TANF). A program that provides cash benefits to low income families with children.  When you qualify for TANF, you generally also qualify for Medicaid.  In addition, Medicaid coverage often continues for a limited time or longer if you no longer qualify for TANF.  See also Medicaid.

U.S. Department of Labor.  A department of the federal government that regulates employer provided health benefit plans.  You may need to contact the Department of Labor if you are in a self-insured group health plan, or if you have questions about COBRA or the Family and Medical Leave Act.  See also COBRA, Family and Medical Leave Act.

Usual and Customary Agreed upon dollar amounts an insurance company will pay for specific types of healthcare treatments