See Activities of Daily Living Standards.A&H, A&S. Accident and Health Insurance, Accident and Sickness Insurance. Once commonly used as generic designations for the entirefield now called Health Insurance. See Health Insurance.
Riders on life insurance policies which allow the lifeinsurance policy's death benefits to be used to offset expenses incurred in a convalescent or nursing homefacility.
The availability of medical care to a patient. This can bedetermined by location, transportation, type of medicalservices in the area, etc.
An older name for Health Insurance. See Health Insurance.
A form of insurance against loss by accidental bodily injuryto the insured.
A policy or a provision in a Disability Income policy whichpays either a specified amount or a multiple of the weeklydisability benefit if the insured dies, loses his or hersight, or loses two limbs as the result of an accident. Alesser amount is payable for the loss of one eye, arm, leg,hand, or foot.
An extra benefit which generally equals the face of thecontract or principal sum, payable in addition to otherbenefits in the event of death as the result of an accident.See also Double Indemnity and Multiple Indemnity.
A form that provides payment if the death of the insuredresults from an accident. It is often combined withDismemberment Insurance in a form called Accidental Deathand Dismemberment. See also Accidental Death andDismemberment.
A Medicare term which means the process of adding newmembers to a health plan.
Most group health insurance policies state that if anemployee is not actively at work on the day the policy goesinto effect, the coverage will not begin until the employeedoes return to work.
Everyday living functions and activities performed byindividuals without assistance. These functions wouldinclude mobility, dressing, personal hygiene and eating.
Used to assess the ability of an individual to liveindependently, measured by the ability to perform unaidedsuch activities as eating, bathing, toiletry, dressing, andwalking. ADL standards are sometimes discussed as a way tomeasure or define eligibility for long term care.
The actual amount charged by a physician for medicalservices rendered.
Skilled, medically necessary care provided by medical andnursing personnel in order to restore a person to goodhealth.
Prescription drugs listed as commonly prescribed byphysicians for patients' long-term use. Subject to review and change by the health plan involved. Also called drugmaintenance list.
Riders added to disability income policies to provideadditional benefits during the first year of a claim whilethe insured is waiting for Social Security benefits tobegin.
The estimated average cost of Medicare benefits establishedon a per county basis _ factors include age, sex, Medicaid,institutional status, disability, and end stage renaldisease status. Used to determine payments to costcontractors for Medicare benefits.
Community rating adjusted by factors specific to aparticular group. Also known as factored rating.
The number of hospital admissions for each 1,000 members ofthe health plan.
The number of admissions to a hospital (including outpatientand inpatient facilities).
A group program for functionally impaired adults, designedto meet health, social and functional needs in a settingaway from the adult's home.
Individualized patient services required afterhospitalization or rehabilitation.
The date on which a person's age, for insurance purposes, changes. In most Life Insurance contracts this is the datemidway between the insured's natural birth dates. Health insurers frequently use the age of the previous birth datefor rate determinations. On the date of age change, aperson's age may change to that of the last birth date, the nearer birth date, or the next birth date, depending uponthe way in which the rating structure has been establishedby that particular insurer.
Compares the age and sex risk of medical costs of one grouprelative to another. An age/sex factor above 1.00 indicateshigher than average risk of medical costs due to thatfactor. Conversely, a factor below 1.00 indicates a lowerthan average risk. This measurement is used in underwriting.
Separate rates are established for each grouping of age andsex categories. Preferred over single and family ratingbecause the rates and premiums automatically reflect changesin the age and sex content of the group. Also sometimescalled table rates.
A maximum dollar amount that may be collected by theclaimant for any disability, for any period of disability,or under the policy as a whole.
Health personnel who perform duties which would otherwisehave to be performed by physicians, optometrists, dentists,podiatrists, nurses, and chiropractors. Also calledparamedical personnel.
Payments authorized for specific purposes with a maximumspecified for each. In hospital policies, for instance,there may be scheduled benefits for X-rays, drugs,dressings, and other specified expenses.
The lesser of the actual charge, the customary charge andthe prevailing charge. It is the amount on which Medicarewill base its Part B payment.
Charges which qualify as covered expenses.Alternative Delivery SystemsSystems which cover health care costs, other than on theusual fee-for-service basis. Could include HMOs, IPAs, PPOs,etc.
A progressive, irreversible disease characterized bydegeneration of the brain cells and severe loss of memorycausing the individual to become dysfunctional and dependentupon others for basic living needs.
Similar to outpatient treatment in that it is care whichdoes not require hospitalization.
Institutions such as surgery centers, clinics, or otheroutpatient facilities which provide health care on anoutpatient basis.
Additional services (other than room and board charges) suchas X-rays, anesthesia, lab work, etc. Fees charged forancillary care such as X-rays, anesthesia, and lab work.This term may also be used to describe the charge made by apharmacy for prescriptions which exceed the health insuranceplan's maximum allowable cost (MAC).
Benefits for miscellaneous hospital charges.
Amounts paid under Medicare as the maximum fee for a coveredservice.
A facility or program which has been approved by a healthcare plan as described in the contract.
An authorization to pay Medicare benefits directly to theprovider. Medicare payments may be assigned to participatingproviders only.
A method where the person receiving the medical benefitsassigns the payment of those benefits to a physician orhospital.
The total cost of administrative and/or medical servicesdivided by the number of units of exposure such as costsdivided by number of admissions, or cost divided by numberof outpatient claims, etc.
The total number of patient days divided by the number ofadmissions and discharges during a specified period of time.This gives the average number of days in the hospital foreach person admitted.
Under the Medicare catastrophic coverage act, payment forprescription drugs is limited to the lowest of thepharmacy's actual charge, the sum of the AWP for the drug plus an administrative allowance, or effective 1992, the90th percentile of pharmacy charges.
