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| Access |
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A person's ability to obtain affordable medical care on a timely basis.
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| Access Fee |
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An Access Fee is the dollar amount that a Covered Person must pay each time certain services are received. The Access Fee is subtracted from Covered Charges before applying any Deductible, Coinsurance or other Out-of-Pocket Limit. An Access Fee will not be reimbursed by the Insurance Carrier nor does it count toward satisfying any Deductible, Coinsurance or other Out-of-Pocket Limit.
An Access Fee only applies if it is shown in the Benefit Summary. The Benefit Summary will identifiy what any applicable Access Fee are along with the Covered Charges to which they apply.
The Following Access Fees may apply to Covered Charges:
1. Facility Fee: Thedollar amount that must be paid directly to the facility for each surgical procedure and each Inpatient stay. A single Inpatient stay insludes readmissions within 30 days for the same condition.
2. Emergency Room Fee: The dollar amount that must be paid directly to the facility for an Emergency Room visit. Many insurance carriers will waive an Emergency Room Access Fee if the Covered Person is admitted for an Inpatient stay immediately following the Emergency Room Visit.
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| Accident or Accidental |
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Any event that meets all of the following requirements: 1. It causes harm to the physical structure of the body. 2. It results from an external agent ortrauma. 3. It is the direct cause of a loss, independent of disease, bodily infirmity or any other cause. 4. It is defined as to time and place. 5. It happens involuntarily, or entails unforeseen consequences if it is the result of an intentional act.
An Accident does not include harm resulting from a Sickness.
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| Accident, Injury |
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means accidental bodily Injury sustained by the Insured which is the direct cause of loss, independent of disease or bodily infirmity.
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| Accidental Death |
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means an accidental bodily Injury that results in death.
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| Accreditation |
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An evaluative process in which a healthcare organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of Quality.
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| Accredited (Accreditation) |
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A "seal of approval" for health care facilities. Being accredited means that a facility has met certain Quality standards. These standards are set by private, nationally recognized groups that check on the Quality of care at health care facilities. Also see Accreditation.
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| Accumulation Period |
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Timeframe within a Policy period in which Deductible and out-of-pocket amounts are calculated. For most Health Insurance (HI) policies, the accumulation period is a Calendar Year.
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| ACF |
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See Ambulatory Care Facility (ACF).
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| Acquisition |
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The purchase of one organization by another organization.
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| ACR |
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See Adjusted Community Rating (ACR).
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| Actuaries |
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The insurance professionals who perform the mathematical analysis necessary for setting insurance Premium rates.
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| Acute Behavioral Health Inpatient Facility |
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See Behavioral Health Inpatient Facility - Acute.
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| Acute Medical Facility (Hospital) |
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See Medical Facility - Acute (Hospital).
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| Acute Medical Rehabilitation Facility |
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See Medical Facility - Acute Rehabilitation.
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| Adjusted Community Rating (ACR) |
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A Rating method under which a Health Plan or MCO divides its Members into classes or groups based on demographic factors such as geography, family composition, and age, and then charges all members of a class or group the same Premium. The plan cannot consider the Experience of a class, group, or tier in developing Premium rates. Also known as Modified Community Rating or Community Rating By Class (CRC).
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| Administration on Aging |
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The Older Americans Act of 1965 established the AoA, which is an agency of the U.S. Department of Health and Human Services. Its mission is to develop a comprehensive, coordinated and cost-effective system of Long Term Care (LTC) that helps elderly individuals to maintain their dignity in their homes and communities.
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| Administrative Services Only (ASO) |
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An arrangement in which an employer hires a third party to deliver employee Benefit administrative services to the employer. These services typically include health Claims processing and billing. The employer bears the risk for health care expenses under an ASO plan.
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| Administrative Services Only (ASO) Contract |
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The contract between an employer and a Third Party Administrator (TPA).
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| Administrator |
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An organization or entity designated by the Insurance Carrier to manage the Benefits previded in the plan. The designated Administrator will have the discretionary authority to act on the Insurance Carriers behalf in the administration of the insurance plan. The Administrator may enter into agreements with various Providers to provide services covered under the plan.
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| Admitting Physician |
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The doctor responsible for admitting you to a Hospital or other Inpatient health facility.
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| Admitting Privileges |
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The right granted to a doctor to admit patients to a particular Hospital.
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| Adverse Selection |
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Selection "against the company." Tendency of less favorable insurance risks to seek or continue insurance to a greater extent than others. Also, tendency of Policy Owners to take advantage of favorable options in insurance contracts.
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| Advocate |
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A person who gives you support or protects your rights.
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| AEP or "Annual Election Period" |
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The Medicare Part D annual period from November 15 until December 31 when a Medicare Beneficiary can enroll into a Medicare Part D plan or re-enroll into their existing Medicare Part D Plan or change into another Medicare Part D plan. Beneficiaries can also switch to aMedicare Advantage Plan that also has a Prescription Drug plan (MA-PD). The chosen Medicare Part D plan Coverage begins on January 1st. Related to this word are IEP, OEP, and SEP..
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| After Care |
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The care or follow-up treatment needed by a patient who has recently undergone surgery, been involved in an accident or has experienced an illness requiring hospitalization.
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| Agent |
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A person who is authorized by an MCO or an insurer to act on its behalf to negotiate, sell, and service Managed Care contracts.
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| Agent of Record |
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The insurance Agent recognized by a client to represent the client's interests in doing business with an insurance company.
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| Aggregate Stop-Loss Coverage |
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A type of Stop-Loss Insurance that provides Benefits when a group's total Claims during a specified period exceed a stated amount.
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| Air Travel Only |
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means while traveling in, including boarding and alighting from, a certified passenger aircraft provided by a commercial airline and operated by a properly certified pilot.
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| Ambulatory Care |
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All types of Health Services that do not require an overnight Hospital stay.
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| Ambulatory Care Facility (ACF) |
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A medical care center that provides a wide range of healthcare services, including Preventive Care, acute care, surgery, and Outpatient Care, in a centralized facility. Also known as a Medical Clinic or Medical Center.
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| Ancillary Services |
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Services, other than those provided by a physician or hospital, which are related to a patient's care, such as laboratory work, x-rays and anesthesia. Auxiliary or Supplemental Services, such as diagnostic services, Home Health Services, Physical Therapy, and Occupational Therapy, used to support Diagnosis and treatment of a patient's condition.
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| Annual Maximum Benefit Amount |
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The maximum dollar amount set by an MCO that limits the total amount the plan must pay for all healthcare services provided to a Subscriber in a year.
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| Annual Notice of Change |
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This is a notice provided by the insurance company that explains which Benefits have changed and how they have changed for the upcoming plan year. It is a notice required by the Centers for Medicare and Medicaid Services (CMS) for all Medicare Part D plans.
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| Antitrust Laws |
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Legislation designed to protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies. See also Sherman Antitrust Act, Clayton Act, and Federal Trade Commission Act.
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| Any Willing Provider Laws |
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Legislation that requires health care plans to accept into their PPO and HMO Networks any Provider willing to agree to the Network's terms and conditions.
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| Appeal |
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Request made to a payer to reconsider a decision, such as a Claim denial or denied Prior Authorization request. Most appeals must be submitted in writing within a specified period. In a Medicare Part D Plan, you can also appeal if your plan decides to stop covering drugs you're currently receiving. There is a specific process you and your prescription drug plan must use when you appeal one of its decisions.
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| Appropriate Care |
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A diagnostic or treatment measure whose expected health Benefits exceed its expected health risks by a wide enough margin to justify the measure.
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| Appropriateness Review |
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An analysis of healthcare services with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided.
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| ASO Contract |
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See Administrative Services Only (ASO) Contract.
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| Assets |
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Property you own that the government may review when you apply for assistance. For help with the costs of a Medicare Prescription Drug Plan, the government counts cash or any property that can be turned into cash within 20 days. This includes checking and savings accounts, certificates of deposit, IRAs and 401(k) plans, stocks, bonds, and similar items. It does not include your primary home, or certain property related to burial expenses.
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| Assignment of Benefits |
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When an insured person assign Benefits, they sign a document allowing the Hospital or doctor to collect Health Insurance (HI) Benefits directly from the Health Insurance (HI) company. Otherwise, the insured person pays for the treatment and is later reimbursed by the Health Insurance (HI) company.
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| Assistant Surgeon |
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A Health Care Parctitioner who is qualified by licensure, training and Credentialing to perform the procedure in an assistant role to the primary surgeon in the state and facility where the procedure is preformed.
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| Associate Medical Director |
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Manager whose duties are often defined as a subset of the overall duties of the Medical Director.
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| At-Risk |
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Term used to describe a Provider organization that bears the insurance risk associated with the healthcare it provides.
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| Attachment |
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A Policy modification which changes, restricts or clarifies Coverage.
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| Authorized Representative |
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The person you designate to assist or handle affairs related to your health care services. This may be someone you designate as a Power of Attorney, a family member, friend, Caregiver, or it may be an Advocate you assign to assist with an exception, Appeal or Grievance.
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| Autonomy |
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An ethical principle which, when applied to Managed Care, states that Managed Care Organization (MCO)s and their Providers have a duty to respect the right of their Members to make decisions about the course of their lives.
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| Aversion Therapy |
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A series of procedures, medications or treatments that are designed to reduce or eliminate unwanted or dangerous behavior through the use of negative experiences, such as pairing the behavior with unpleasant sensations or punishment.
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