Health Insurance Glossary G-M

For this health insurance glossary G - M, please note that definitions of terms may vary among insurance companies and across states.

G

Gatekeeper: A term used to describe the role of the primary care physician in an HMO plan. The primary care physician serves as the patient's main point of contact for healthcare services and refers patients to specialists for specific needs.

Generic Drug: A drug which is the same as a brand name prescription drug, but which can be produced by other manufacturers after the brand name drug's patent has expired. Usually less expensive than brand name drugs.

Grace Period: A time period after the payment due date, during which insurance coverage remains in force and the policyholder may make a payment without penalty.

Grievance Procedure: The procedure by which a member or healthcare service provider can file a complaint with a health insurance company and seek remedy for a claim dispute.

Group: A number of individuals covered under a single health insurance contract, usually a group of employees.

Group Health Insurance: A health insurance plan that provides benefits for employees of a business or members of an organization, as opposed to individual and family health insurance.

Guaranteed Issue: Insurance coverage that must be issued regardless of health status of a member. In many states, larger group health plans may be guaranteed issue plans, because a health insurer cannot refuse coverage to a qualifying business or organization based on the health status of their employees or members. In some states, all health insurance plans are guaranteed issue.

Guaranteed Renewable Contract: A contract under which the insured person is guaranteed the right, usually up to a certain age, to renew and continue a health insurance policy by the timely payment of premiums.

H

Health Insurance: Insurance against financial losses resulting from sickness or accidental bodily injury. It offers protection that provides payment of benefits for covered sickness or injury. Types of insurance included are accident, disability income, medical expense and accident death and dismemberment.

Health Insurance Portability and Accountability Act of 1996 (HIPAA): Legislation mandating specific privacy rules and practices for medical care providers and health insurance companies. It also provides additional protections for consumers to help them obtain or retain health insurance coverage in certain circumstances.

Health Maintenance Organization (HMO): A health insurance program that provides a wide range of comprehensive healthcare services through a network of doctors, hospitals, labs, etc. who agree to provide services to HMO members at a pre-negotiated rate (capitation). Except in case of emergency, member choice of doctors is often restricted to those in the network. An HMO typically offers low cost but restricts choice of service providers and may limit services.

Health Savings Account (HSA): A tax advantaged savings account to be used in conjunction with certain high-deductible (low premium) health insurance plans to pay for qualifying medical expenses. Contributions are made to the account on a tax-free basis. Funds may accumulated in the account from year to year and may be invested at the discretion of the individual owning the account. Interest or investment returns accrue tax-free. Penalties may apply when funds are withdrawn to pay for anything other than qualifying medical expenses.

Health Reimbursement Arrangement (HRA): An employer-sponsored program by which the employer reimburses employees for qualified healthcare related expenses incurred by employees upon submission of evidence of expense by employee to employer.

Home Health Care: Part-time care that is provided by medical professionals in the home setting rather than in a hospital or skilled nursing facility.

Hospice Care: Care rendered either on an inpatient basis or in the home setting for a terminally ill patient. Also referred to as "palliative" care, hospice care emphasizes the management of pain and discomfort and the emotional support of the patient and family.

Hospital Benefits: Benefits payable for hospital room and board and other miscellaneous charges resulting from hospitalization.

Hospitalization Insurance: Insurance intended to provide coverage in case of hospitalization, including benefits for room and board and miscellaneous expenses, within certain limitations.

I

Individual Practice Association (IPA): An organization of physicians who may maintain separate offices but who negotiate contracts with insurance companies and medical facilities as a group.

Incontestable Clause: A provision in an insurance policy that states that the validity of the insurance contract cannot be contested after two, or sometimes three, years.

Indemnity: Legal principle that specifies that an insured should not collect more than the actual cash value of a loss, but should be restored to approximately the same financial position as existed before the loss.

Indemnity Plan: See Fee For Service Plan.

Independent Agent: An independent business person who represents and writes insurance policies with two or more insurance companies in a sales and service capacity and who is paid a commission for business production.

Individual and Family Health Insurance: Health insurance purchased by an individual or family, independent of any employer or organizationgroup plan. In most states, a health insurance company may decline coverage for an individual or family health insurance plan based on the medical conditions or health histories of the applicants or dependents.

Infertility Services: Any medical services to assist with child conception.

Inpatient: Describes the care rendered in a hospital when the duration of patient stay is at least 24 hours.

Insurable Risk: The conditions that make a risk insurable are (a) the peril insured against must produce a definite loss not under the control of the insured; (b) there must be a large number of homogeneous exposures subject to the same perils; (c) the loss must be calculable and the cost of insuring it must be economically feasible; (d) the perils must be unlikely to affect all insureds simultaneously; and, (e) the loss produced by a risk must be definite and have a potential to be financially serious.

Insured: A person or organization covered by an insurance policy, including the “named insured” and any other parties for whom protection is provided under the policy terms.

Insurer: The party to the insurance contract who promises to pay losses or benefits. Also any corporation or other entity engaged primarily in the business of furnishing insurance to the public.

Integrated Delivery System: A group of doctors, hospitals and other providers who work together to deliver a broad range of healthcare services.

Intermediate Care: A level of nursing care, considered less intensive than skilled nursing care, but which may be rendered in a skilled nursing or intermediate care facility.

J

K

L

Lab Benefits: Typically, any diagnostic lab test or diagnostic/therapeutic services performed in support of basic health services. Lab services typically include services like blood panels and urinalysis.

Lapse: The termination of insurance coverage due to lack of payment after a specific period of time.

Lifetime Maximum: The maximum dollar amount that a health insurance company agrees to pay on behalf of a member for covered services during the course of patient lifetime.

Limitations: Any maximums that a health insurance plan imposes on specific benefits.

Long-term Care: Care provided on a continuing basis for the chronically ill or disabled. Long-term care may be provided on an inpatient basis at a long-term care facility such as a nursing home or in the home setting.

M

Major Medical Insurance: A type of medical insurance plan that provides broad benefits for most types of medical expenses up to a high maximum coverage after a substantial deductible and usually subject to coinsurance.

Managed Care: A variety of healthcare and health insurance programs that attempt to guide a member's use of benefits by requiring the member to coordinate healthcare through a primary care physician, or by encouraging the use of a specific network of healthcare providers. The intent is to keep costs and monthly premiums low. Different types of managed care health plans including Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Point of Service (POS) plans.

Maternity Services: Inpatient services include hospitalization and physician fees associated with the birth of a child. Outpatient services include OB-GYN office visits during pregnancy and immediately after giving birth.

Maternity Coverage: Maternity insurance covers part or all of the medical cost during a woman's pregnancy, typically broken down into inpatient and outpatient services.

Maximum Out-Of-Pocket Costs: The most an insured patient will be required to pay out-of-pocket in a benefit year, often including co-payments coinsurance and deductibles.

Medicaid: A federally-funded, state-administered healthcare program for low income and disabled persons.

Medical Insurance Bureau (MIB): A data pool service that stores coded information on health histories of persons who have applied for insurance from subscribing companies.

Medical Necessity: A basic standard of health insurance companies to determine if healthcare services should be covered. Covered services are considered to meet the criteria when they are appropriate, consistent with general standards of medical care, consistent with a patient's diagnosis, and the least expensive option available to provide a desired health outcome. This standard may not apply to preventive care services.

Medical Savings Account (MSA): A tax-advantaged personal savings account used in conjunction with a high-deductible health insurance plan. MSA’s are not as beneficial as HSA’s and are currently being phrased out and replaced with HSAs.

Medical Tourism: The practice of a patient arranging for healthcare services by traveling to medical service providers in locations outside the patient’s home country for a treatment or procedure. The primary benefit is usually much lower cost or access to services or treatment not available to the patient at home.

Medicare: A national, federally-administered health insurance program authorized to cover the cost of hospitalization, medical care, and some related health services for most people over age 65.

Medicare Beneficiary: Anyone entitled to Medicare benefits based on the rules for eligibility outlined by the Social Security Administration.

Medicare Supplement Insurance: Health insurance offered to a Medicare-eligible individual that is designed to help fill in the gaps in the coverage provided by Medicare.

Minimum Group: The fewest number of employees permitted under state law to qualify for group insurance. It may be as few as two. The purpose is to maintain proper division between individual and group insurance forms.

For a term beginning with A or B, go to Glossary a-b;

For a term beginning with C, D, E or F, go to Glossary C-F;

For a term beginning with N, O, P or Q, go to Glossary N-Q;

For a term beginning with R, S, T, U, V, W, X, Y or Z,, go to Glossary R-Z;