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| Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) |
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This act defines the primary and Secondary Coverage responsibilities of theMedicare program and also the provisions to be used by Health Plans in their contracts with the HCFA (Health Care Financing Administration (HCFA)).
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| Telehealth Services |
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The use of modern telecommunication and information technologies by a Health Care Practitioner in the treatment of his or her established patient.
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| Telemedicine Services |
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A medical inquiry initiated by a Health Care Practitioner for the purpose of assistance with a patient's assessment, Diagnosis, consultation, treatment or the transfer of medical data that requires the use of modern telecommunications technology.
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| Temporary Disability Benefits (TDB) |
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Legislated Benefits payable to employees for nonoccupational disabilities under TDB laws in certain states. See also Disability Benefits Law.
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| Temporary Partial Disability |
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A condition where an injured party's capacity is impaired for a time, but he is able to continue working at reduced efficiency and is expected to fully recover.
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| Temporary Total Disability |
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A condition where an injured party is unable to work at all while he is recovering from Injury, but he is expected to recover.
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| Temporomandibular Joint (TMJ) Dysfunction and Craniomandibular Joint (CMJ) Dysfunction |
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TMJ Dysfunction and CMJ Dysfunction is any joint disorder of the jaw causing:
1. Clicking and/or difficulties in opening and closing the mouth.
2. Pain or welling.
3. Complications including arthritis, dislocation and bite problems of the jaw.
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| Ten Day Free Look |
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A notice, placed prominently on the face page of the Policy, advising the Insured of his or her right to examine a health policy, and if dissatisfied return the policy within ten days for a full refund of Premium and no further obligation.
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| Term of Insurance |
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means the time period beginning with the Effective Date and ending with the expiry date stated in the Schedule Page.
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| Terminally Ill |
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A term which refers to the status of a person who will normally die within 6 months of a specific illness or Sickness. Often refers to the Terminally Ill requirement for Hospice Care.
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| Termination Provision |
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A Provider contract clause that describes how and under what circumstances the parties may end the contract.
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| Termination With Cause |
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A contract provision, included in all standard Provider contracts, that allows either the MCO or the Provider to terminate the contract when the other party does not live up to its contractual obligations.
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| Termination Without Cause |
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A contract provision that allows either the MCO or the Provider to terminate the contract without providing a reason or offering an Appeals process.
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| Terrorism or Act of Terrorism |
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means an act, including but not limited to the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s), committed for political, religious, ideological or similar purposes or reasons including intention to influence any government and/or to put the public, or any section of the public, in fear.
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| Tertiary Care |
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Services provided by such Providers as thoracic surgeons, intensive care units, neurosurgeons, etc.
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| Therapeutic Alternatives |
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Alternate drug products which may be different in chemical content, but provide the same effect when administered to patients.
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| Therapeutic Equivalence |
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Different drugs which will control a symptom or illness exactly the same as other drugs used to control that illness.
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| Therapeutic Substitution |
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The dispensing of a different chemical entity within the same drug class of a drug listed on the Formulary of a Pharmacy Benefit Management (PBM) Plan. Therapeutic Substitution always requires physician approval.
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| Third Party Administrator (TPA) |
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A firm which provides administrative services for employers and other associations having Group insurance policies. The TPA in addition to being the liaison between the employer and the insurer is also involved with certifying eligibility, preparing reports required by the state and processing Claims. TPA's are being used more and more with the increase in employer Self-Funded Plans.
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| Third-Party Payer |
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Any payer of health care services other than the insured person. This can be an insurance company, HMO, PPO, or the federal government.
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| Ticket Policy |
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See Transportation Ticket Policy.
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| Tier |
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A Formulary is often divided into tiers. Each tier represents a different level of cost-sharing for Prescription Drugs. As the tiers rise, Members pay more for the listed drugs. For example, a tier-1 drug may cost you a $7.50 Copay, and a tier-3 drug may cost you a $50 Copay. UnitedHealth RX plans have four tiers, and your cost-sharing amount depends on which tier your drug is listed under.
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| Time Limit on Certain Defenses |
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One of the uniform individual accident and Sickness provisions required by state law to be included in every Individual Health Policy. It sets a limit on the number of years after a policy has been in force that an insurer can use as a defense against a Claim the fact that a physical condition of the Insured existed before the policy was issued, but was not declared at that time.
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| Title XIX Benefits |
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SeeMedicaid.
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| Total Disability/Totally Disabled |
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A degree of disability from Injury or Sickness that prevents the Insured from performing the duties of any occupation from remuneration or profit. The definition in any given case depends on the wording in a covering Policy.
As an example: You or Your spouse are unable to perform the essential duties of any occupation for which reasonably fitted be education, training or experience, whether performed for financial gain or not. Retired individuals and homemakers shall not be considered unable to perform an occupation solely because they are unemployed. If You are unemployed, a determination will be made based on if You are unable to engage in the normal and customary activities of a person of the same age and sex. A Covered Dependent child is Totally Disabled only if confined as a patient in an Acute Medical Facility (Hospital) or Behavioral Health Facility.
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| TPA |
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See Third Party Administrator (TPA).
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| Transportation Ticket Policy |
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An Accidental Death and Dismemberment and Disability Benefit Policy issued with a Common Carrier ticket and limited to the risks or travel and the duration of the trip for which the ticket has been purchased. The name is derived from the fact that it was originally issued in the form of an extra stub on a travel ticket.
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| Travel Accident Insurance |
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A form of Health Insurance (HI) limiting Coverage to accidents occurring while the Insured is traveling.
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| Treatment Codes |
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See Diagnostic And Treatment Codes.
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| Treatment Facility |
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Any facility, either residential or nonresidential, which is authorized to provide treatment for mental illness or Substance Abuse.
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| Trend Factor |
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The factor applied to rates which allows for such changes as increased cost of medical Providers, the cost of new and expensive medical technology, etc.
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| Triage |
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A method of ranking sick or injured people according to the severity of their Sickness or Injury in order to ensure that medical and nursing staff facilities are used most efficiently.
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| TRICARE |
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A healthcare plan, available to more than 6 million military personnel and their families, which is administered by private contractors who are selected for Participation through a competitive procurement process. TRICARE offers Members three plan options: TRICARE Prime (a capitated HMO with nominal Premiums and Copayments), TRICARE Extra (a PPO with standard CHAMPUS Deductibles), and TRICARE Standard (the current Fee-for-Service CHAMPUS plan with Provider choice and no Premiums). See also Civilian Health And Medical Program of The Uniformed Services (CHAMPUS).
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| Triple Option |
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A plan where employees have their choice, among different types of provides such as HMO, PPO, or basic indemnity plan. Usually, their choice depends on how much they want to pay for the Coverage.
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| TrOOP - True Out-of-Pocket |
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True Out-of-Pocket Costs. Those costs you pay for which you are not reimbursed.
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