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| Date of Service |
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The date that the health service was provided.
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| DBL |
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See Disability Benefits Law.
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| Death Spiral |
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The potentially destructive cycle that may occur in an indemnity plan as a result of increased HMO penetration. The process can occur if indemnity plan rates continuously escalate because healthier and younger employees choose HMOs, leaving less healthy individuals in experience-rated indemnity plans. Employer Contribution strategies and HMO pricing techniques may aggravate the problem.
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| Deductible |
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A Deductible is the dollar amount of Covered Charges that must be paid before Benefits are paid by the Insurance Carrier.
Plans have varying types of Deductibles. This may depend on whether the Covered Person's Health Care Practitioner belongs to a particular Network or not. A Deductible only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what the applicable Deductibles are along with the Covered Charges to which they apply.
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| Deductible - Common Accident |
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If more than one Covered Person is injured in the same Accident, only one Individual Deductible must be satisfied for all Covered Charges for that Accident. The Covered Charges must be Incurred within the first 90 days after the date the Accident occurs. Covered Charges Incurred more than 90 days after the date the Accident occurs will be paid subject to all the terms, limits and conditions in the plan without regard to the Common Accident Deductible provision.
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| Deductible - Condition Specific |
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The dollar amount of Covered Charges that must be satisfied by a Covered Person because of a named condition, shown on a Condition Specific Deductible endorsement that is included with the plan, and for any complications related to that named condition. When Covered Charges equal to the Condition Specific Deductible for the named condition have been Incurred and processed by the Insurance Carrier, the Condition Specific Deductible for that Covered Person will be satisfied for the remainder of the time period shown in the Condition Specific Deductible endorsement. After the Condition Specific Deductible is satisfied, additional Covered Charges for the named condition will be paid subject to all the terms, limits and conditions in the plan, including satisfaction of any other applicable Coinsurance, Deductible or other fees.
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| Deductible - Family |
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The dollar amount of Covered Charges that must be satisfied by all Covered Person before Benefits are payable by the Insurance Carrier. The Individual Deductibles that all Covered Persons may have to pay are limited to the Family Deductible amount. When the Family Deductible amount is reached, the Insurance Carrier will consider the Deductible requirements for all Covered Persons in Your family to be satisfied for the remainder of the Calendar Year, except for any Condition Specific Deductible that a Covered Person may have.
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| Deductible - Individual |
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The dollar amount of Covered Charges each Covered Person must satisfy before Benefits are payable by the Insurance Carrier. When Covered Charges equal to the Individual Deductible have been Incurred and processed by the Insurance Carrier, the Individual Deductible for that Covered Person will be satisfied for the remainder of the Calendar Year.
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| Deductible - Integrated |
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Covered Charges Incurred by all Covered Persons, including Covered Charges for Prescription Drugs, count toward satisfying a single Deductible. When Covered Charges equal to the Integrated Deductible have been Incurred and processed by the Insurance Carrier, the Integrated Deductible for all Covered Persons will be Satisfied for the remainder of the Calendar Year.
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| Deductible - Non-Participating Provider |
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The dollar amount of Covered Charges received from Providers in Nonparticipating Providers that each Covered Person must satisfy before Benefits are payable by the Insurance Carrier. When Covered Charges equal to the Nonparticipating Provider Deductible have been Incurred and processed by the Insurance Carrier, the Nonparticipating Provider Deductible for that Covered Person will be satisfied for the remainder of the Calendar Year.
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| Deductible - Participating Provider |
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The dollar amount of Covered Charges received from Providers in Participating Provider Network that each Covered Person must satisfy before Benefits are payable by the Insurance Carrier. When Covered Charges equal to the Participating Provider Deductible have been Incurred and processed by the Insurance Carrier, the Participating Provider Deductible for that Covered Person will be satisfied for the remainder of the Calendar Year.
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| Deductible Carryover Credit |
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During the last three months of a Calendar Year, charges incurred for Health Services can be used to satisfy the Deductible for the following Calendar Year. These credits may be applied whether or not the prior Calendar Year's Deductible had been met.
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| Defensive Medicine |
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Use of unnecessary treatments, procedures or other medical services by doctors to minimize the threat of a malpractice lawsuit
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| Deferred Compensation Administrator |
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This refers to a company that provides services under a deferred compensation plan. Services may include administration of Self-Insured Plans, compensation planning, salary surveys, retirement planning, etc.
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| Delete |
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This refers to the process of taking an individual offMedicare Coverage.
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| Demand Management |
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The use of strategies designed to reduce the overall demand for and use of healthcare services, including any Benefit offered by a plan that encourages Preventive Care, wellness, Member self-care, and appropriate Utilization of Health Services.
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| Denial Of Claim |
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Refusal by a Health Insurance (HI) company to honor a request by an individual (or his or her Provider) to pay for health care services obtained from a health care professional.
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| Dental Health Maintenance Organization (DHMO) |
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An organization that provides dental services through a Network of Providers to its Members in Exchange for some form of prepayment.
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| Dental Injury |
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Injury resulting from an Accidental blow to the mouth causing trauma to teeth, the mouth, gums or supporting structures of the teeth.
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| Dental Insurance |
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A Group Health Insurance contract that provides payment for certain enumerated dental services.
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| Dental Point Of Service (Dental POS) Option |
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A dental service plan that allows a Member to use either a DHMO Network dentist or to seek care from a dentist not in the HMO Network. Members choose In-network care or Out-Of-Network care at the time they make their dental appointment and usually incur higher Out-of-Pocket Costs for Out-Of-Network care.
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| Dental POS Option |
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See Dental Point Of Service (Dental POS) Option.
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| Dental PPO |
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See Dental Preferred Provider Organization (Dental PPO).
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| Dental Preferred Provider Organization (Dental PPO) |
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An organization that provides dental care to its Members through a Network of dentists who offer discounted fees to the plan Members.
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| Dental Treatment Plan |
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A dentist's report of recommended treatment on a form satisfactory to the Insurance Carrier that:
1. Itemizes the dental procedures and charges required for care of the mouth; and
2. Lists the charges for each procedure; and
3. Is accompanied by supporting preoperative imaging tests and any other appropriate diagnostic materials required by the Insurance Carrier.
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| Department of Health and Human Services |
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A federal department whose responsibility is primarily dealing with social service functions such as administration and supervision of theMedicare program.
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| Dependent |
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A Dependent is:
1. The Certificate Holder's lawful spouse; or
2. The Certificate Holder's naturally born child, legally adopted child, a child that is placed for adoption with the Certificate Holder, a stepchild or a child for which the Certificate Holder is the legal guardian:
a. Who is unmarried; and
b. Who is age 18 or younger; and
c. Who is claimed as an exemption on Your most recent federal income tax return, except for a Dependent child who is a Full-Time Student; and
d. Whose legal address is the same as the Certificate Holder's legal address
If the child's legal address is different than the Certificate Holder, the child will be considered a Dependent if You submit proof that:
a. You are required by a qualified medical child support order to provide medical insurance; or
b. The child was claimed as an exception on Your most recent federal income tax return.
If Your unmarried child is age 19 or older, the child will be considered a Dependent if You give the insurance carrier proof that;
a. The child is a Full-Time Student at an accredited educational institution, college or university. A student will be considered full-time if the student meets the standards for full-time status as the school the student is attending. A student will be considered full-time during regular vacation periods that interrupt, but do not terminate, the continuous full-time course of study; or
b. The child is not capable of self-sustaining employment or engaging in the normal and customary activities of a person of the same age because of mental incapacity or physical handicap. The child must also be chiefly dependent on the Certificate Holder for financial support and be claimed as an exemption on Your most recent federal income tax return. You must give the insurance carrier proof that the child meets these requirements at the same time that You first enroll for coverage under this plan or within 31 days after the child reaches the normal age for termination. Additional proof may be requested periodically following the date the child reaches the normal age for termination.
A child will not longer be a Dependent on the earliest of the date that he or she:
a. Is no longer a full-time student; or
b. Graduates; or
c. Ceases to be claimed as an exemption on the Certificate Holder's federal income tax return, except for a Dependent child who is a Full-Time Student; or
d. Attains age 24; or
& nbsp; e. Marries.
3. A grandchild of the Certificate Holder born to a Covered Dependent will be covered from birth through age 18 months, or until the Benefit Period ends, which ever comes first.
If only Dependent children are covered under this plan, the youngest child will be considered the Certificate Holder. All siblings of the Certificate Holder will be considered Covered Dependents if they meet the requirements above.
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| Dependent Coverage |
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Insurance Coverage on the head of a family which is extended to his or her Dependents, including only the lawful spouse and unmarried children who are not yet employed on a full-time basis. "Children" may be step, foster, and adopted, as well as natural. Certain age restrictions on children usually apply.
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| Designated Facility |
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A facility which has an agreement with a Health Insurance (HI) plan to render approved services (Organ transplants are the most common example.). The facility may be outside a covered
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| Designated Mental Health Provider |
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The organization hired by a Health Plan to provide mental health and Substance Abuse services.
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| Designated Transplant Provider |
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A Health Care Practitioner, facility or supplier, as determined by the Insurance Carrier, that a Covered Person must use to obtain the maximum Benefits available under the Transplant Services provision in the Medical Benefits section.
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| Detoxification |
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The process an individual goes through when withdrawing from alcohol. Usually is done under guidance of medical personnel.
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| Developmental Delay |
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A child who has not attained developmental milestones for the child's age, adjusted for prematurely, in one or more of the following areas of development: cognitive; physical (including vision and hearing); communication; social-emotional; or adaptive development. A Developmental Delay is a delay that has been measured by qualified personnel using informed clinical opinion and appropriate diagnostic procedures and/or instruments. A Developmental Delay must be documented as:
1. A 12 month delay in one functional area; or
2. a 33% delay in one functional area or a 25% delay in ach of two areas (when expressed as a quotient of developmental age or chronological age); or
3. A score of at least 2.0 standard deviations below the mean in one functional area or a score of at least 1.5 standard deviations below the mean in each of two functional areas if appropriate standardized instruments are individually administered in the evaluation.
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| DHMO |
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See Dental Health Maintenance Organization (DHMO).
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| Diagnosis |
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The process of identifying a disease.
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| Diagnosis Related Groups (DRGs) |
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A method of classifying Inpatient Hospital services. Developed byMedicare, healthcare cost scheduled (grouped) so that medical service Providers are assigned a uniform payment for specific services.
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| Diagnostic And Treatment Codes |
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Special codes that consist of a brief, specific description of each Diagnosis or treatment and a number used to identify each Diagnosis and treatment.
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| Diagnostic Imaging |
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Procedures and test including, but not limited to, x-rays, magnetic resonance imaging (MRI) and computerized axial tomography (CT), that are preformed to diagnose a condition or determine the nature of a condition.
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| Disability Benefit |
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A feature of some policies for the Waiver of Premium if the Policyholder becomes permanently and Totally Disabled.
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| Disability Benefits Law |
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A state law requiring an employer to provide Disability Benefits to covered employees for nonoccupational injuries, in contrast to Workers' Compensation, which pays for occupational injuries. These laws are currently in effect in New York, New Jersey, Rhode Island, California, and Hawaii.
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| Disability Buy-Sell |
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A disability income Policy used to fund a disability buy-sell agreement whereby the business interest of a disabled stockholder following the Elimination Period. The Policy's Benefits may be paid in a lump sum or in installments.
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| Disability Income Insurance |
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A form of Health Insurance (HI) that provides periodic payments to replace income, actually or presumptively lost, when the Insured is unable to work as a result of Sickness or Injury.
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| Disability Insurance Training Council, Inc |
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The educational arm of the International Association of Health Underwriters, the Health Insurance (HI) agents' professional society. It seeks to encourage agent educational projects by local Health associations, conducts university seminars in advanced Health Underwriting areas, and conducts annual seminars for Home Office executives in sociological social insurance and demographic trends that may affect future application of policy forms and Health Insurance (HI).
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| Disability Insurance Waiting Period |
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The period of time between the beginning of a disability and the start of Disability Insurance Benefits. Also called Elimination Period.
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| Disability, Long-Term |
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See Long-Term Disability Insurance.
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| Disability, Permanent Partial |
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See Permanent Partial Disability.
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| Disability, Permanent Total |
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See Permanent Total Disability.
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| Disability, Short-Term |
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See Short-Term Disability.
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| Disability, Temporary Partial |
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See Temporary Partial Disability.
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| Disability, Temporary Total |
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See Temporary Total Disability.
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| Discharge Planning |
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Medical personnel of a Health Plan working with the attending physician and Hospital staff to assess alternatives to hospitalization, evaluate appropriate settings for care, and arrange for the discharge of a patient, including planning for subsequent care at home or in a Skilled Nursing Facility. The goal is to determine when patients are ready to go home, and to provide a more comfortable, cost-efficient setting for continued treatment.
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| Disease Management (DM) |
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A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, Quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as Disease State Management.
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| Disease State Management |
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See Disease Management (DM).
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| Disenroll |
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When you disenroll, you end your Coverage in a prescription drug or other Health Plan. Your plan can choose to disenroll you under specific circumstances.
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| Dismemberment |
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The loss of, or loss of use of, specified members of the body resulting from accidental bodily Injury.
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| Dismemberment Benefit |
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The Benefits payable for various types of dismemberment. See also Accidental Death and Dismemberment and Multiple Indemnity.
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| DM |
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See Disease Management (DM).
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| Doughnut (Donut) Hole |
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The gap in your Coverage that spans between ordinary drug Coverage and Catastrophic Coverage. In this gap, the Medicare Beneficiary pays 100% of their prescription costs. According to the federal government, about 88% of Medicare beneficiaries who enrolled in a Medicare Part D plan do not have Doughnut (Donut) Hole Coverage. The standard or model Part D Coverage begins with a Deductible of $295 followed by a co-pay of 25% on the next $2405 (you pay $601.25). Upon reaching the total medication costs of $2700 (with $896.25 out of pocket), Coverage ceases and the Beneficiary is 100% responsible for all costs during a "blackout period" known as the "Doughnut (Donut) Hole" or "Coverage Gap", until a new spending tier, an additional $3453.75 out of pocket, is reached and Coverage kicks in again at the "Catastrophic" level. See Coverage Gap.
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| Dread (or Specified) Disease Policy |
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Coverage, usually with a high maximum limit, for all types of medical expenses arising out of diseases named in the contract. Common diseases covered are poliomyelitis, diphtheria, multiple sclerosis, spinal meningitis, and tetanus. Cancer is sometimes covered or may be added with some companies by a Rider.
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| DRG |
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See Diagnosis Related Groups (DRG).
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| Drive Time |
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A measure of Geographic Accessibility determined by how long Members in the plan's Service Area have to drive to reach a Primary Care Provider (PCP).
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| Drug Cards |
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See Pharmaceutical Cards.
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| Drug Formulary |
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A schedule of Prescription Drugs approved for use which will be covered by the plan and dispensed through Participating Provider pharmacies.
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| Drug Price Review (DPR) |
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A procedure used to determine drug price maximums. It involves determining wholesale drug prices based on the American Druggist Blue Book.
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| Drug Utilization Review (DUR) |
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A review program that evaluates whether drugs are being used safely, effectively, and appropriately.
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| Dual Choice |
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The federal requirement that employers having 25 or more employees who are within the Service Area of a federally qualified HMO, who are paying at least minimum wage and offer a Health Plan to their employees, must offer HMO Coverage as well as an indemnity plan.
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| Dual Eligibles |
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People eligible for bothMedicare andMedicaid.
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| Due Process Clause |
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A Provider contract provision which gives Providers that are terminated with cause the right to Appeal the termination.
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| Duplicate Coverage Inquiry (DCI) |
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A request to determine whether or not other Coverage exists. Used to apply the Coordination of Benefits (COB) provisions where two or more insurance companies are involved.
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| Duplication of Benefits |
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A situation where identical or overlapping Coverage exists between two or more insurance companies or service organizations.
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| DUR |
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See Drug Utilization Review (DUR).
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| Durable Medical Equipment |
|
Equipment that meets all of the following requirements:
1. It is designed for and able to withstand repeated use.
2. It is primarily and customarily used to serve a medical purpose.
3. It is used by successive patients.
4. It is suited for use at home.
5. It is normally rented.
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