Health Insurance Glossary
We want you to know the ins-and-outs of health insurance. That's why we've built this glossary of terms because we know that although the words are English, they often have different meanings than what we know them to be. You can check for a specific term that you are curious about or read the entire glossary if you are prepared for the most fun-filled day you have ever had. Enjoy.A-C D-F G-K L-N O-Q R-T U-Z
Lab's and X-Ray's are diagnostic and therapeutic ancillary services performed on patients to help analyze and treat a patient's ailments. Some X-Ray services include MRI's, Ultrasounds, CT Scans, while Lab tests may encompass blood panels and urinalysis. X-Rays from dentist visits are typically covered by standard health insurance.
A Lapse refers to the temporary loss of health insurance coverage due to unpaid premiums.
Length of Stay (LoS)
A Length of Stay is the total number of days a patient remains in a medical facility such as a hospital.
Lifetime Maximum Amount
Lifetime Maximum Amount is the dollar amount that a health insurance company determines is the maximum amount that they will pay out for medical expenses incurred within the lifetime of the insured or member.
Limitations are the maximums amount a non-network medical physician is allowed to bill for a specific medical service.
Long-Term Care is a medical service that is available to individuals with chronic or disabling diseases or conditions. Some health insurance company's cover all long-term care costs.
Mail-Order Pharmacy Programs
Mail Order Pharmacy Programs offer prescription drugs that are ordered and delivered through the mail to reduce costs. Pharmacies do not have to pay for high priced retail locations and can process orders less expensively and accurately to meet the patients needs.
Major Medical Insurance
Major Medical Insurance is a type of health insurance that provides medical benefits for a range or medical services subject to a large deductible. There may be limits to charges like room and board.
Managed Behavioral Health Organization (MBHO)
Managed Behavioral Health Organizations (MBHO) provide behavioral health care services to insureds though an organized delivery system and implementing managed care techniques. These organizations have processes to monitor, evaluate, and increase quality and safety provided to patients.
Managed Care is a medical delivery system that offers low-cost, high-quality medical services to individuals.
Managed Indemnity Plans
Managed Indemnity Plans are similar to traditional Indemnity plans but may require precertification, or prior authorization for certain services and procedures. Members have access to any provider they choose, then pay their predetermined deductible and co-insurance and then are reimbursed for the remaining medical expenses.
Management Services Organization (MSO)
A Management Services Organization (MSO) is an organization that is owned by a hospital, physician group, or a group of investors that manage and offer administrative support to individual providers or small group practices. Some Management Services Organizations (MSO) provide these services for a designated fee, while others purchase buildings, equipment and supplies and then lease them back to the providers for a fee.
Inpatient Maternity refers to the medical costs associated with the birth of a child and hospitalization stay. These costs also include physician fees.
Outpatient Maternity refers to medical services received outside of a hospital for the care and treatment of a woman's pregnancy. Treatment is supervised and monitored by an OB/GYN.
Maternity Coverage refers to the time that a woman stays in the hospital following the birth of a child. This medical coverage refers to inpatient and outpatient care.
Max Duration is a short-term health insurance policy that ends after a short duration of time.
The Maximum Allowable is a limited amount of money that a health insurance provider will pay for benefits in a specified amount of time.
Maximum Out-of-Pocket Costs
The Maximum Out-of-Pocket Costs are the most costs an insured person will pay for out-of-pocket medical expenses . Those expenses may include copayments, coinsurance, deductibles, etc.
Medicaid is a federal medical program available to low-income and disabled individuals for certain medical and hospital expenses.
Medical Advisory Committee
A Medical Advisory Committee for a health insurance plan reviews policies, provider contracts, compensation, changes in procedures and medical policies then makes suggestions based on their review.
A Medical Director is a physician who provides leadership and oversight on the quality of care given to patients by a group of physicians or practice.
Medical Underwriting is the process of using a patients passed medical history and that of their family members to make a determination to offer coverage. This process allows the health insurance company decide who to offer coverage to, who to deny and if there should be additional charges or exclusions. Medical Underwriting helps health insurance companies avoid adverse selection.
Medically Appropriate Services
Medically Appropriate Services are diagnostic or treatment procedures in which the benefits out way the risks.
Medically Necessary Services
Medically Necessary Services are diagnostic or treatment of an illness or injury, disease or symptom that may be justified as reasonable and necessary to meet the generally accepted standards of medical care. These services must also be appropriate in type, frequency, duration and be considered effective for the patients illness, injury or disease. These services are not solely for the convenience of the patient or provider and are not more costly than other reasonable alternatives of treatment.
The Messenger Model was outlined in the 1996 Department of Justice/Federal Trade Commission Statements of Antitrust Enforcement Policy in Health Care. The Messenger Model allows independent providers to market themselves as a network. The messenger can then manage the process of negotiating fees of the individual providers with the health insurance plans, and allows the providers to market themselves as a network.
National Association of Insurance Commissioners (NAIC)
The NAIC is an organization of insurance entities formed to regulator health insurance.
National Drug Code
An NDC is a classification system used to identify prescription drugs. These codes are similar to the universal product code (UPC).
The Network is a group of doctors, hospitals, pharmacies and other medical experts hired by a health insurance provider to offer medical care to its participants.
A Network Provider is a contract medical professional who agrees to provide a level of medical care to patients. This agrement is with a health insurance provider.
Non-Duplication of Benefits
Non-Duplication of Benefits is a provision made by some health insurance provider stateing that benefits reimbursed by others will not be paid for.
A Nursing Home is a specialized facility licensed by and approved by a state for skilled nursing care. Care may include rehabilitation or restorative services.