HS 311 key terms

The tendency for people with higher-than-average health risks to seek or keep coverage more often than low-risk people, which can raise claim costs for an insurer unless underwriting or enrollment rules control it.

The insurer's process of evaluating an applicant's health history, age, occupation, and other risk factors to decide whether to issue coverage and at what premium or rating class.

The increased likelihood of loss or higher claims that occurs because having insurance reduces a person's incentive to avoid risky behavior or to control spending on care.

Combining many individuals' potential losses into one group so the cost of claims is spread across all members, making each person's financial exposure more predictable and affordable.

The amount an insured person or plan sponsor pays, usually monthly, to keep an insurance policy or health plan in force regardless of whether any claims are filed.

A traditional health plan that pays a set percentage of covered charges after a deductible is met, leaving the insured free to use any licensed provider and responsible for the balance.

A delivery system that controls cost and quality by contracting with a network of providers and applying rules such as primary care gatekeeping, referrals, and utilization review.

A plan that provides care through a defined provider network, usually requires members to choose a primary care physician, and generally pays nothing for non-emergency care outside the network.

A plan that contracts with providers for discounted rates and pays more when members use in-network care, while still allowing out-of-network care at a higher share of cost.

A hybrid plan that combines HMO-style gatekeeping and in-network benefits with the option to see out-of-network providers at a reduced benefit level, often after a referral.

A government-run or state-run exchange where individuals and small employers compare and buy qualified health plans, often with premium tax credits based on household income.

A health plan certified by the Marketplace that meets required benefit, cost-sharing, and network standards, making enrollees eligible for subsidies and protections.

A set of ten broad service categories, such as hospitalization, prescription drugs, maternity care, and mental health care, that certain individual and small-group plans must cover.

A defined window each year when individuals can newly enroll in or change health coverage without needing a special qualifying event.

A change such as marriage, divorce, birth of a child, or loss of other coverage that allows a person to enroll in or change health insurance outside the annual open enrollment period.

The amount an insured must pay toward covered medical expenses in a benefit period before the insurer begins paying its share of the cost.

The percentage of covered expenses, after the deductible is satisfied, that the insured and the insurer each pay, such as an 80/20 split.

A fixed dollar amount the insured pays at the time of a covered service, such as a set charge per office visit or per prescription, rather than a percentage of the cost.

The most an insured must pay in deductibles, coinsurance, and copayments during a benefit period before the plan pays covered expenses in full.

A fee benchmark based on the prevailing charges for a service in a geographic area, used by some plans to limit reimbursement and leave the excess billed amount to the patient.

The practice of a provider billing a patient for the difference between the provider's charge and the amount the insurer allows or pays.

Rules that determine the order in which two or more health plans pay when a person is covered by more than one, preventing total payments from exceeding the actual expense.

The waiting period after a disability or illness begins during which no benefits are payable, after which eligible benefits start.

The maximum length of time for which benefits are payable under a policy, such as two years or to age 65, measured from the start of the covered condition.

A disability standard that considers an insured disabled if unable to perform the material duties of their own specific occupation, usually the most favorable and costly definition for the insured.

A disability standard that considers an insured disabled only if unable to perform the duties of any occupation for which they are reasonably suited by training, education, or experience.

A partial disability benefit that pays a reduced amount when the insured returns to work but earns less than before the disability, usually tied to the percentage of lost income.

A benefit that pays a stated amount when an accident causes death or the loss of a limb, sight, or other specified body part, typically in addition to other accident coverage.

The base amount stated in an accidental death and dismemberment policy, from which scheduled percentages are paid for specific losses such as a hand or an eye.

Coverage that pays specified benefits for injuries caused by accidental means, often on a fixed-indemnity basis, and typically excludes illness and injuries from expected events.

Coverage that pays benefits for illness or disease, as distinguished from accidental injury, and is often sold as a fixed-indemnity policy paying set amounts per day or per service.

A fixed-indemnity policy that pays a stated daily or per-admission amount for a hospital stay, regardless of the actual charges incurred.

Coverage that pays for services such as nursing home care, home health care, and assisted living when an insured cannot perform activities of daily living or has cognitive impairment.

Basic self-care tasks such as bathing, dressing, eating, toileting, transferring, and continence, used as a trigger for long-term care benefits when a person cannot perform a set number.

Hospital insurance that helps pay for inpatient hospital stays, skilled nursing facility care after a hospital stay, hospice, and some home health care, generally without a monthly premium for those with enough work history.

Medical insurance that helps pay for physician services, outpatient care, preventive services, and durable medical equipment, funded partly by a monthly premium paid by enrollees.

A private plan approved by Medicare that provides Part A and Part B benefits, often with drug coverage and extra benefits, in place of original Medicare.

Optional outpatient prescription drug coverage delivered through private stand-alone plans or through Medicare Advantage plans that include drug benefits.

A joint federal-state program that pays for health coverage for eligible low-income children, pregnant women, parents, older adults, and people with disabilities, with eligibility rules set by each state.

Coverage issued to an employer or other organization that covers a defined group of members and their dependents, usually with guaranteed issue and premiums shared with the employer.

A federal law that lets eligible employees and dependents keep group health coverage for a limited time after a qualifying event such as job loss, at their own expense.

A policy provision stating that after the policy has been in force for a set period, usually two years, the insurer cannot void coverage because of misstatements on the application.

A period after a premium due date, commonly 7 to 31 days depending on the policy, during which coverage stays in force even though the payment is late.

A provision stating that the policy, the attached application, and any riders or endorsements make up the whole agreement, limiting outside documents from changing its terms.