Health Insurance Terms A

Helpfull Health insurance terms A

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ADL
See Activities of Daily Living Standards.

A&H, A&S. Accident and Health Insurance, Accident and Sickness Insurance
Once commonly used as generic designations for the entire field now called Health Insurance. See Health Insurance.

Accelerated Benefits
Riders on life insurance policies which allow the life insurance policy's death benefits to be used to offset expenses incurred in a convalescent or nursing home facility.

Access
The availability of medical care to a patient. This can be determined by location, transportation, type of medical services in the area, etc.

Accident and Health Insurance (A&H)
An older name for Health Insurance. See Health Insurance.

Accident and Sickness Insurance (A&S)
An older name for Health Insurance. See Health Insurance. (H)

Accident Insurance
A form of insurance against loss by accidental bodily injury to the insured. (H)

Accidental Death and Dismemberment
A policy or a provision in a Disability Income policy which pays either a specified amount or a multiple of the weekly disability benefit if the insured dies, loses his or her sight, or loses two limbs as the result of an accident. A lesser amount is payable for the loss of one eye, arm, leg, hand, or foot.

Accidental Death Benefit
An extra benefit which generally equals the face of the contract or principal sum, payable in addition to other benefits in the event of death as the result of an accident. See also Double Indemnity and Multiple Indemnity.

Accidental Death Insurance
A form that provides payment if the death of the insured results from an accident. It is often combined with Dismemberment Insurance in a form called Accidental Death and Dismemberment. See also Accidental Death and Dismemberment.

Accrete
A Medicare term which means the process of adding new members to a health plan.

Actively-at-work
Most group health insurance policies state that if an employee is not actively at work on the day the policy goes into effect, the coverage will not begin until the employee does return to work.

Activities of Daily Living (ADL)
Everyday living functions and activities performed by individuals without assistance. These functions would include mobility, dressing, personal hygiene and eating. (H)

Activities of Daily Living (ADL) Standards
Used to assess the ability of an individual to live independently, measured by the ability to perform unaided such activities as eating, bathing, toiletry, dressing, and walking. ADL standards are sometimes discussed as a way to measure or define eligibility for long term care.

Actual Charge
The actual amount charged by a physician for medical services rendered. (H)

Acute Care
Skilled, medically necessary care provided by medical and nursing personnel in order to restore a person to good health.

Additional Drug Benefit List
Prescription drugs listed as commonly prescribed by physicians for patients' long-term use. Subject to review and change by the health plan involved. Also called drug maintenance list.

Additional Monthly Benefit
Riders added to disability income policies to provide additional benefits during the first year of a claim while the insured is waiting for Social Security benefits to begin.

Adjusted Average Per Capita Cost (AAPCC)
The estimated average cost of Medicare benefits established on a per county basis _ factors include age, sex, Medicaid, institutional status, disability, and end stage renal disease status. Used to determine payments to cost contractors for Medicare benefits.

Adjusted Community Rating (ACR)
Community rating adjusted by factors specific to a particular group. Also known as factored rating.

Admissions/1,000
The number of hospital admissions for each 1,000 members of the health plan.

Admits
The number of admissions to a hospital (including outpatient and inpatient facilities).

Adult Day Care
A group program for functionally impaired adults, designed to meet health, social and functional needs in a setting away from the adult's home.

Aftercare
Individualized patient services required after hospitalization or rehabilitation.

Age Change
The date on which a person's age, for insurance purposes, changes. In most Life Insurance contracts this is the date midway between the insured's natural birth dates. Health insurers frequently use the age of the previous birth date for rate determinations. On the date of age change, a person's age may change to that of the last birth date, the nearer birth date, or the next birth date, depending upon the way in which the rating structure has been established by that particular insurer.

Age/Sex Factor
Compares the age and sex risk of medical costs of one group relative to another. An age/sex factor above 1.00 indicates higher than average risk of medical costs due to that factor. Conversely, a factor below 1.00 indicates a lower than average risk. This measurement is used in underwriting. (H)

Age/Sex Rates (ASR)
Separate rates are established for each grouping of age and sex categories. Preferred over single and family rating because the rates and premiums automatically reflect changes in the age and sex content of the group. Also sometimes called table rates. (H)

Aggregate Indemnity
A maximum dollar amount that may be collected by the claimant for any disability, for any period of disability, or under the policy as a whole. (H)

Allied Health Personnel
Health personnel who perform duties which would otherwise have to be performed by physicians, optometrists, dentists, podiatrists, nurses, and chiropractors. Also called paramedical personnel. (H)

Allocated Benefits
Payments authorized for specific purposes with a maximum specified for each. In hospital policies, for instance, there may be scheduled benefits for X-rays, drugs, dressings, and other specified expenses. (H)

Allowable Charge
The lesser of the actual charge, the customary charge and the prevailing charge. It is the amount on which Medicare will base its Part B payment. (H)

Allowable Costs
Charges which qualify as covered expenses.

Alternative Delivery Systems
Systems which cover health care costs, other than on the usual fee-for-service basis. Could include HMOs, IPAs, PPOs, etc. (H)

Alzheimer's Disease
A progressive, irreversible disease characterized by degeneration of the brain cells and severe loss of memory causing the individual to become dysfunctional and dependent upon others for basic living needs.
Ambulatory Care
Similar to outpatient treatment in that it is care which does not require hospitalization. (H)

Ambulatory Setting
Institutions such as surgery centers, clinics, or other outpatient facilities which provide health care on an outpatient basis.
Ancillary
Additional services (other than room and board charges) such as X-rays, anesthesia, lab work, etc. Fees charged for ancillary care such as X-rays, anesthesia, and lab work. This term may also be used to describe the charge made by a pharmacy for prescriptions which exceed the health insurance plan's maximum allowable cost (MAC).
Ancillary Benefits
Benefits for miscellaneous hospital charges.
Approved Charge
Amounts paid under Medicare as the maximum fee for a covered service. Approved Health Care Facility or Program
A facility or program which has been approved by a health care plan as described in the contract.

Assignment
An authorization to pay Medicare benefits directly to the provider. Medicare payments may be assigned to participating providers only.

Assignment of Benefits
A method where the person receiving the medical benefits assigns the payment of those benefits to a physician or hospital.

Average Cost Per Claim
The total cost of administrative and/or medical services divided by the number of units of exposure such as costs divided by number of admissions, or cost divided by number of outpatient claims, etc.

Average Length of Stay (ALOS)
The total number of patient days divided by the number of admissions and discharges during a specified period of time. This gives the average number of days in the hospital for each person admitted.

Average Wholesale Price (AWP)
Under the Medicare catastrophic coverage act, payment for prescription drugs is limited to the lowest of the pharmacy's actual charge, the sum of the AWP for the drug plus an administrative allowance, or effective 1992, the 90th percentile of pharmacy charges.