Health Insurance Terminology

This set of flashcards contains key terminology and definitions related to health insurance concepts, aimed at assisting in the review for an exam.

Conversion Factor (Relative Value Scale)

A system used to assign units to services representing relative costs, allowing adjustments through dollar value changes.

Deductible

The amount an insured must pay before their health insurance policy begins to pay benefits.

Essential Health Benefits (EHBs)

A list of 10 benefits defined by the ACA that cannot have lifetime or annual caps.

Family Deductible

A deductible that limits the total amount due from the entire covered family, typically two or three times the individual deductible.

Flat Deductible (Initial Deductible)

A stated dollar amount applied to a covered loss, which can be per-occurrence, per-insured, or per-year.

Flexible Spending (Accounts) Arrangements (FSAs)

Tax-advantaged accounts where employees set aside earnings for qualified medical expenses on a 'use it or lose it' basis.

First-Dollar Coverage

Insurance policies that pay claims without imposing a deductible.

Gold Plan

An ACA metal tier plan that has an actuarial value of 80% of typical medical costs.

Health Insurance Exchange

A federal website for consumers to check eligibility for assistance and compare health insurance plans.

Health Insurance Portability and Accountability Act (HIPAA)

Legislation limiting pre-existing condition exclusions and establishing privacy rules for health information.

Health Reimbursement (Accounts) Arrangements (HRAs)

Employer-funded accounts that cover cost-sharing amounts like deductibles and coinsurance, accumulating unused amounts yearly.

Health Savings Accounts (HSAs)

Portable, tax-advantaged medical savings accounts for U.S. taxpayers enrolled in high-deductible health plans.

High-Deductible Health Plan (HDHP)

A policy that makes the insured responsible for basic expenses while setting an annual limit on out-of-pocket costs.

Impairment Rider

A rider in health insurance policies that permanently excludes claims for disclosed conditions.

Integrated Deductible

A deductible used when a major medical plan is combined with basic coverages, where basic payments apply to major deductibles.

Internal Limits (Inside Limits)

Annual limits on coverage for specific covered services.

Look-Back Period

The defined period before coverage starts during which an insurer can identify a health concern as pre-existing.

Major Medical (Expense) Insurance Policy

A health insurance policy with broad coverage and high benefits for hospitalization, surgery, and physician services.

Medical Savings Accounts (MSAs)

Tax-free accounts for small employer's employees and self-employed individuals to pay for medical expenses.

Metal Tiers for Major Medical Insurance

ACA-defined levels of coverage including Bronze, Silver, Gold, and Platinum.

Out-of-Pocket Maximum

The maximum amount an insured must pay for covered services in a single plan year.

Per-Cause (or Occurrence) Deductible

A deductible that must be satisfied for each accident or illness.

Platinum Plan

An ACA metal tier plan with an actuarial value projected to cover 90% of typical medical costs.

Portability

The ability to retain access to a group insurance policy when changing employers.

Pre-Existing Condition

A health condition existing prior to insurance coverage inception.

Pre-Existing Condition Exclusion

Temporary exclusions for undisclosed conditions treated during the look-back period.

Relative Value (Approach) Scale

An approach used in surgical insurance to establish benefits based on single unit values for covered surgeries.

Silver Plan

An ACA metal tier plan with an actuarial value projected to cover 70% of typical medical costs.

Stop-Loss

The maximum amount of coinsurance an insured paid in one year, often synonymous with out-of-pocket maximum.

Usual, Customary, and Reasonable (UCR) (Non-Scheduled Plans)

Plans that compare expenses to what is reasonable and customary for the location of the service.