Chapter 6 - Medical Expense Insurance

Actuarial Value

The minimum projected percentage of medical costs covered by a medical expense policy.

Affordable Care Act (ACA)

Legislation enacted to make health insurance more accessible and affordable through mandates and subsidies.

Basic Hospital Expense Insurance

Policies covering hospital room, board, and miscellaneous hospital expenses up to a maximum.

Basic Medical Expense Insurance

Health policies providing "first-dollar" benefits for specified, limited health care services.

Basic Physician Expense Insurance

Policies covering non-surgical services provided by a physician.

Basic Surgical Expense Insurance

Policies covering surgeon and anesthesiologist fees, regardless of where surgery is performed.

Benefit Period

The timeframe benefits are paid or claims are counted against cost-sharing limits.

Bronze Plan

An ACA metal tier plan projected to cover 60% of medical costs.

Cafeteria Plans

Employee benefit arrangements allowing selection of various benefits on a pre-tax basis.

Calendar-Year Deductible

A deductible that the insured must meet only once during the benefit period.

Carryover Provision

Allows claims from the final three months of a year to apply to next year's deductible.

Conversion Factor

The dollar value per unit used to adjust a relative value scale schedule.

Deductible

The amount an insured must pay before the health insurance policy begins paying benefits.

Essential Health Benefits (EHBs)

A list of 10 necessary benefits that cannot have lifetime or annual caps.

Family Deductible

A deductible that limits the total amount due from an entire covered family.

Flat Deductible

A stated dollar amount applied to a covered loss before benefits are paid.

Flexible Spending Accounts (FSAs)

Tax-advantaged accounts set up through employers 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 projected to cover 80% of medical costs.

Health Insurance Exchange

A federal website to check eligibility for assistance and purchase health plans.

HIPAA

Legislation limiting pre-existing condition exclusions and protecting personal health information privacy.

Health Reimbursement Arrangements (HRAs)

Employer-funded, non-portable accounts covering cost-sharing amounts like deductibles.

Health Savings Accounts (HSAs)

Portable, tax-advantaged accounts for individuals enrolled in a high-deductible health plan.

High-Deductible Health Plan (HDHP)

A policy making insureds responsible for basic expenses while capping annual out-of-pocket costs.

Impairment Rider

An policy addition permanently excluding claims for a disclosed pre-existing condition.

Integrated Deductible

A deductible where amounts paid by a basic policy apply to major medical limits.

Internal Limits

Annual limits on coverage for specific, individual covered services.

Look-Back Period

The period preceding coverage during which insurers can identify pre-existing conditions.

Major Medical Expense Insurance

Comprehensive health policies featuring high benefit limits, deductibles, and coinsurance.

Medical Savings Accounts (MSAs)

Tax-free accounts helping small employers and self-employed individuals pay medical expenses.

Out-of-Pocket Maximum

The absolute most an insured must pay for covered services in a single year.

Per-Cause Deductible

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

Platinum Plan

An ACA metal tier plan projected to cover 90% of medical costs.

Portability

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

Pre-Existing Condition

A health condition existing prior to the inception of insurance coverage.

Silver Plan

An ACA metal tier plan projected to cover 70% of medical costs.

Stop-Loss Provision

A policy provision limiting the insured's total out-of-pocket medical expenses.

Usual, Customary, and Reasonable (UCR)

A geographic-based standard used to determine coverage payment limits for non-scheduled plans.

Coinsurance

The percentage participation in covered expenses shared between insurer and insured after deductibles.

Corridor Deductible

The deductible gap between basic coverage and major medical coverage.

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