Common Health Insurance Terminology (GHI)
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Gatekeeper
Role description of the primary care physician in HMOs who serves to control
utilization and referral of enrollees.
Generic Drug
A drug which is exactly the same as a brand name drug and which is allowed to be
produced after the brand name drug's patent has expired. It is also called a
"generic equivalent."
Grace Period
Specified time (usually 31 days) following the premium due date during which
insurance remains in force and a policyholder may pay the premium without
penalty.
Grievance Procedure
A procedure which allows a member of a health plan or a provider of benefits to
express complaints and seek remedies.
Group
Coverage of a number of individuals under one contract. The most common
"group" is employees of the same employer.
Group Certificate
The document provided to each member of a group plan. It shows the benefits
provided under the group contract issued to the employer or other insured.
Group Model HMO
A health plan where a group of physicians is reimbursed for services they
provide at a negotiated rate. The HMO also contracts with hospitals for the care
of the patients of the physicians who belong to the group.
Guaranteed Renewable
Contract
Contract under which an insured has the right, commonly up to a certain age, to
continue the policy by the timely payment of premiums. Under renewable
contracts, the insurer reserves the right to change premium rates by policy
class.
Guaranteed Standard
Issue (GSI)
An underwriting term used to describe the fact that a group insurance contract
was issued without reference to any medical underwriting. All group participants
are covered regardless of health history.
Home Health Agency
A certified facility approved by a health plan to provide services under
contract.
Home Health Care
Care received at home as part-time skilled nursing care, speech therapy,
physical or occupational therapy, part-time services of home health aides or
help from homemakers or choreworkers.
Health Care Financing Administration (HCFA)
Part of the Department of Health and Human Services, responsible for
administration of the Medicare and Medicaid programs. The HCFA establishes
standards for medical providers which must be complied with if the provider is
to meet certification requirements.
Health History
A form used by underwriters to assist in evaluating groups or individuals to
determine whether they are acceptable risks.
Health Plan
This refers to any kind of plan that covers health care services such as HMOs,
insured plans, preferred provider organizations, etc.
Health Insurance (HI)
Insurance against loss by sickness or bodily injury. The generic form for those
forms of insurance that provide lump sum or periodic payments in the event of
loss occasioned by bodily injury, sickness or disease, and medical expense. The
term Health Insurance is now used to replace such terms as Accident Insurance,
Sickness Insurance, Medical Expense Insurance, Accidental Death Insurance, and
Dismemberment Insurance. The form is sometimes called Accident and Health,
Accident and Sickness, Accident, or Disability Income Insurance.
Health Insurance
Association of America (HIAA)
An association supported by Life and Health insurers to provide the research,
public relations, education, and legislative base for the promotion of voluntary
private Health Insurance.
Health Insurance
Institute (HII)
The public relations arm of the Health Insurance Association of America. It
provides for a flow of information from Health insurers to the public and from
the public to the insurers.
Health Insurance
Portability and Accountability Act (HIPAA)
A federal law passed in 1996 that provided numerous protections for persons who
were losing their insurance coverage due to changes in employment status. HIPAA
provided for accessibility to coverage for a person who moved from one employer
sponsored plan to another employer sponsored plan, by providing for guaranteed
acceptance and waiver of pre-existing condition exclusions based upon the time
covered under the prior employer plan.
HIPAA also addressed the issue of accessibility to coverage for a person who chose to leave an employer sponsored plan and obtain coverage in the individual market. If such person meets the qualifications under HIPAA as a Federally Eligible Individual ("FEI") he or she is entitled to coverage on a guaranteed issue basis in the individual market with a complete waiver of pre-existing condition exclusions. This coverage must be provided by an insurance company that is currently marketing insurance products in the individual market unless the state where the FEI resides has elected to provide coverage to FEI's under an alternative mechanism. The most prevalent alternative mechanism is a state risk pool.
Federally Eligible Individual, "FEI", is defined under HIPAA as a person who: 1. Has had at least 18 months of continuous coverage with no break in coverage greater than 63 days (may be longer in some states); 2. Most recent coverage was under a group health plan (defined as an employee welfare plan), a governmental plan or a church plan; 3. Is not eligible for coverage under a group health plan, Part A or B of Medicare, Medicaid or similar state plan; 4. Does not have other health insurance; and, 5. Has exhausted coverage under any federal or state continuation of coverage provisions (COBRA) if eligible.
HMO (Health Maintenance
Organization)
Prepaid health plans in which you pay a monthly premium and the HMO covers your
cost of care to see doctors within their network at pre-negotiated rates. You
must choose a primary care physician who coordinates all of your care and makes
referrals to any specialists you might need. If you are an HMO member and you do
not use the doctors, hospitals and clinics that participate in your plan's
network, you will usually bear the cost of those medical services.
Health Service
Agreement (HSA)
The agreement between employer and the health plan which outlines a description
of benefits, enrollment procedures, eligibility standards, etc.
Health Services
The benefits covered under a health contract.
HEDIS® (Health Plan
Employer Data and Information Set)
HEDIS is NCQA's tool used by health plans to collect data about the quality of
care and service they provide. HEDIS consists of a set of performance measures
that tell how well health plans perform in key areas: quality of care, access to
care and member satisfaction with the health plan and doctors. HEDIS requires
health plans to collect data in a standardized way so that comparisons are fair
and valid. Health plans can arrange to have their HEDIS results verified by an
independent auditor.
Hospice
An organization which is primarily designed to provide pain relief, symptom
management and supportive services for the terminally ill and their families.
Hospice care is covered under Part A of Medicare.
Hospital Affiliation
A contract whereby one or more hospitals agrees to provide benefits to members
of a specific health plan.
Hospital Benefits
Benefits payable for hospital room and board, plus miscellaneous charges
resulting from hospitalization.
Hospitalization
Insurance
A form of insurance that provides reimbursement within contractual limits for
hospital and specific related expenses arising from hospitalization caused by
injury or sickness.
IPA (Independent
Practice Association)
An independent group of physicians who contract with an HMO to provide services
for the HMO members. Some health insurance applications will ask for a
physician's IPA number. It can usually be found in an online provider directory
for the health plan or by calling the physician's office.
In-Area Services
Services which are provided within the "authorized" service area as
designated in the plan.
Incontestable Clause
A provision in a policy that the insurer may not contest the validity of an
insurance contract after it has been in force for two (sometimes three) years.
Indemnity Plan
Traditional health insurance that usually covers a percentage of the cost of
care (often 80%) after the consumer pays an annual deductible. Patients with
indemnity coverage can choose any doctor or hospital for their care.
Individual Insurance
A policy that provides protection to a policyholder and/or his or her family;
sometimes called personal insurance, as distinct from group and blanket
insurance.
Initial Eligibility
Period
The time period during which prospective members can apply for coverage without
providing evidence of insurability.
Insurance
Risk management plan that, for a price, offers the insured an opportunity to
share the costs of possible financial loss through an insurer.
Insuring Clause
Stipulation in an insurance policy that states the type of loss the policy
covers and lists the parties to the contract.
Integrated Delivery
System
A group of doctors, hospitals and other providers who work together to deliver a
broad range of health care services.
Intermediate Care
A level of care associated with a skilled nursing facility which provides
nursing care under the supervision of physicians or a registered nurse. The care
provided is a step down from the degree of care described as skilled nursing
care.
Intermediate Care
Facility
A facility licensed by the state, which provides nursing care to persons who do
not require the degree of care which a hospital or skilled nursing facility
provides.
John K. Arnold
Florida Health Insurance
Group, Employee Benefits & Individual Health Insurance Specialist
Website Address www.floridahealthinsurance.com
E-Mail:
John K Arnold
Phone: 407-592-0311 (Best number to reach me)
Phone: 407-830-0259
Fax: 407-386-7053
If outside the US, it is best to e-mail as we can respond more
quickly. Thanks.
Let me know how I can help you.