Chapter 10. Terms to Know

Appeal

a request for a higher authority to review the decision.

Blanket policy

covers members of a particular group when they are participating in a particular activity, without naming individual insureds (such as students, passengers, sports teams)

Capitation

a payment arrangement that pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care

Gatekeeper

a primary care physician (PCP) in an HMO plan

Indemnity plan

pays health policy benefits to the insured based on a predetermined, fixed rate, regardless of the actual expense incurred

Nonrenewal

policy termination at its expiration date

Out-of-pocket expenses

amounts an insured must pay for coinsurance and deductibles before the insurer will pay its portion

Reimbursement

the act of repaying a party who has spent or lost money

Stop-loss

the amount that the insured pays out of pocket during the year

Subscriber

a person who signs up for a prepaid health plan, such as an HMO