Health Insurance Glossary N-Q

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

N

National Association of Insurance Commissioners (NAIC): An association of state officials charged with regulating insurance.

National Drug Code (NDC): A system employed by healthcare for classifying and identifying drugs. Each prescription drug in common use is assigned an NDC number.

Network: A group of physicians, hospitals, and other healthcare service providers that contract to offer services to a health insurance plan's members at discounted rates. For health plan members, the cost to use network providers is less than using out-of-network providers.

Network Provider: A healthcare service provider that is contracted to offer services as part of a network program to health plan members.

Nursing Home: A licensed facility which provides general nursing care to those who are chronically ill or who require constant supervision and assistance with the needs of daily living.

O

Office Visit: An outpatient visit to a physician's office for illness or injury.

Office Visit Copay: The amount you pay when you see the doctor or dentist for routine care. Select higher copay amounts to lower monthly premiums.

Open Enrollment Period: A period during which eligible employees or other members may sign up for coverage under a group health insurance plan, typically without being required to provide evidence of insurability.

Out-of-Network Care: Healthcare services rendered to a patient by a provider outside of the insurance company's network of preferred providers. Typically, the health insurer will pay a lower percentage of cost for these services.

Out-of-pocket Costs: Portion of healthcare costs that are borne by an insured patient, including such costs as coinsurance, deductibles, etc.

Out-of-Pocket Maximum: Maximum Out-of-pocket Costs an insured patient must pay during a specified period, typically a year.

Outpatient: A patient or services received by a patient who receives care at a medical facility but who is not admitted to the facility overnight or receives care for less than 24 hours

Outpatient Surgery: Typically, any surgical procedure that does not require an overnight stay in a hospital.

Over-the-counter (OTC) Drugs: Drugs that may be obtained without a prescription.

P

Part-Time Employee: Typically, for the purposes of qualifying for group health insurance, a part-time employee is one working less than 30 hours per week, while the threshold for full-time employment is usually 30 or more hours. Exact requirements may differ with state limits and with employer specifications.

Partial Disability: A condition resulting from an illness or injury by which a group health insurance member cannot perform all the duties of occupation, but can perform some. Exact definitions differ between health insurance plans.

Peer Review: The process by which a physician or team of healthcare specialists, of equal or better credentials, review the services, course of medical treatment, or the conclusions of a scientific medical study conducted by another physician or group of medical experts.

Periodic Health Exam: Typically, a periodic health exam is an exam that is occurs on a regular basis for preventative purposes, like a routine physical or annual check-up.

Periodic OB-GYN Exam: Typically, a periodic OB-GYN exam is a routine OB-GYN exam that occurs on a regular basis, typically for preventative purposes, like a PAP smear.

Physical Therapy: Rehabilitative services provided by a licensed physical therapist to help restore bodily functions such as walking, speech, the use of limbs, etc.

Plan Type: The healthcare plan design utilized by a health insurance company. Typical plan types include a Point of Service Plan (POS); a Preferred Provider Organization Plan (PPO); a Health Maintenance Organization (HMO); an Indemnity Plan, also called a Fee-For-Service Pan; and an Exclusive Provider Plan (EPO).

Point of Service Plan (POS): A type of managed care health insurance plan. Benefit levels vary depending on whether you receive your care in or out of the health insurance company's network of providers. POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you will likely be required to designate a primary care physician who will then make referrals to network specialists when needed. You may receive care from non-network providers but with greater out-of-pocket costs. With a POS plan, you may be responsible for co-payments, coinsurance and an annual deductible.

Policy Term: The period of time, typically one year, for which a health insurance policy provides coverage.

Practical Nurse: A licensed nurse who provides "custodial" care services, such as assistance in walking, bathing, feeding, etc.. Usually, practical nurses do not administer medications or perform other strictly medical services.

Pre-Admission Authorization/Preauthorization/Precertification: Terms that are often used interchangeably, which refer to specific processes in a health insurance or healthcare context by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug to comply with health insurance company requirements. The insurance company may require that the patient's doctor submit notes and/or lab results documenting the patient's condition and treatment history.

Pre-existing Condition: A health issue that existed or was treated before the effective date of your health insurance coverage. Most health insurance has a pre-existing condition clause that describes conditions under which the health insurance company will cover medical expenses related to a pre-existing condition.

Pre-existing Condition Exclusion: In some cases, a health insurance company may exclude a patient's pre-existing conditions from coverage under a new health insurance plan. This is more typical with individual and family health insurance plans than with group health plans. HIPAA legislation imposes some limitations on excluding coverage for a pre-existing condition.

Preferred Provider Organization (PPO): A type of managed care health insurance plan that allows a member to visit any in-network physician or service provider desired without first requiring a referral from a primary care physician. Services will typically be covered at a higher benefit level when rendered by an in network provider. A member of a PPO plan will not be required to choose a primary care physician, but may go to specialists of choice. PPO plans may require co-payments or coinsurance and almost always require an annual deductible before coverage begins.

Premium: The amount paid to the insurance company for health insurance coverage, typically a monthly charge. With employer group health insurance coverage, the premium is paid in whole or in part by the employer on behalf of the employee and the employee's dependents.

Prescription Medication: A drug approved by the Food and Drug Administration that may be obtained only with a doctor's prescription.

Prescription Drug Coverage: Prescription drug insurance coverage varies by carrier and plan type. Typically, prescription drugs are covered either as a percentage of cost after a plan deductible is met or as the balance of drug cost after a copay by the patient.

Preventive Care: Medical care that is focused on prevention and early-detection of disease, best exemplified by routine examinations and immunizations. Some health insurance plans limit coverage for preventive care services, while others encourage such services. Some preventive care such as well-baby care, immunizations, periodic prostate exams, pap smears and mammograms may be covered even if your health insurance plan limits coverage for other preventive care services. May also be called “preventative care”.

Primary Care: Basic healthcare services, usually offered by physicians who practice family medicine, pediatrics or internal medicine.

Primary Care Physician (PCP): A primary care physician usually serves as a patient's main healthcare provider. The PCP is a first point of contact for healthcare and may refer a patient to specialists for additional services.

Primary Coverage: If a patient is covered under more than one health insurance plan, primary coverage is the coverage provided by the health insurance plan that pays on claims first. (See Coordination of Benefits).

Probationary Period: A waiting period determined by the health insurance company during which coverage for certain pre-existing conditions may be excluded.

Provider: A term commonly used by health insurance companies to designate any healthcare service provider, whether a doctor or nurse, a hospital or clinic.

Provider Write-off: The difference between the actual charge and the allowable charge, which a network service provider cannot charge to a patient who belongs to a health insurance plan that utilizes the provider network. In effect, any amount over an Allowable Charge.

Q

Qualifying Event: An event that triggers a group health insurance member's protection under COBRA. Examples are termination of employment, divorce or the death of the employee.

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 G, H, I, J, K, L or M go to Glossary G-M;

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