Definitions of Words Used by Insurers

Advocate
An individual who defends and speaks for the best interests of the child.
Annual Maximum Limits or Caps
The limit an insurance plan sets on a given service. It may be a number of visits or a dollar amount. If your child needs more than is allowed, you can request an exception.
Benefits
Health care and related services payable by a health insurance plan.
Carrier
The insurance company or the one who agrees to pay the losses. The carrier may be organized as a company or as an Association of Underwriters.
Case Management Program
Special programs offered by some insurance companies, particularly for individuals who require high-cost care. Under such programs, a case manager is assigned to oversee all claims and arrange for alternative benefits. These alternative benefits are not allowed to be more costly than the stated benefits in the plan.
Cerebral Palsy
This is a disorder of movement and posture. The condition is caused by brain damage which occurs before birth, during the birth process, or later in childhood.
Children with Special Health Care Needs
Children with chronic medical conditions and/or acquired disabilities that have a significant impact on home life and school life and require ongoing professional services.
Children's Health Insurance Program (CHIP)
A health insurance program for children from low-income to moderate-income families who are ineligible for Medicaid and are not covered under other health insurance plans.
Claim
A request for payment submitted to a health insurance plan for services.
Coinsurance
A policy provision frequently found in major medical insurance, by which both the insured and the insurer share the covered losses under a policy in a specified ratio.
Continuous Eligibility
Financial eligibility is determined for a 12-month period, regardless of monthly highs or lows in family income.
Conversion
The process by which you shift health coverage from a group plan to an individual plan without review of your insurability.
Coordination of Benefits
The process for how benefits will be applied if you have more than one private health coverage plan. Regulations on benefit coordination may exist within your state, or your insurance plan may describe how such coordination should happen. Usually one plan is designated to pay all claims first, and any remaining bills are the responsibility of the secondary carrier. These provisions prevent multiple payments for the same medical charge.
Co-Payments
The portion of the charge that you are responsible for when you use a health service. Indemnity plans typically require a co-payment to be a percentage of the charge for the service. It may vary based on the type of service, when the service was received (for example within a certain number of days of an emergency), or where the service was received (out-patient versus in-patient facility). When there is a co-payment in managed care plans, it is usually a small fixed amount regardless of the cost of the service.
Current Procedural Technology (CPT)
A set of codes developed by the American Medical Association that describes medical procedures for billing. Each item submitted by your provider to an insurance company for payment must be listed by code on the bill.
Deductible
Annual amount that the consumer agrees to pay for health services before the insurance plan pays.
Developmental Disability
Any mental and/or physical disability that begins before age 22 and may continue indefinitely. It can limit major life activities. This term encompasses individuals with mental retardation, cerebral palsy, autism, epilepsy (and other seizure disorders), sensory impairments, congenital disabilities, traumatic injuries, or conditions caused by disease, such as polio and muscular dystrophy.
Developmentally Delayed
A term used to describe a young child (under the age of 3 years) who is slow in developing but has the potential to catch up. Frequently used to describe a premature infant or a child who has suffered a prolonged illness and, as a result, is delayed in developing.
Diagnosis
A diagnosis is the name of a specific disease or condition. The value of establishing a diagnosis is to provide a basis for treatment.
Discharge Planning
A discharge plan is the plan of medical care and therapy recommended for the patient after leaving the hospital. The discharge plan is developed from the recommendations of the physician, nurse, physical therapist, occupational therapist, speech therapist, and other health care providers involved in the child's care. A social worker or designated discharge planner helps patients and families with planning and arranging this ongoing care.
Eligibility Criteria
A set of terms and restrictions determining who can participate in a program. Each program has its own set of eligibility criteria.
Exclusions
Specific conditions or circumstances listed in the policy for which the policy will not provide benefit payments.
Fee for Service
A form of payment where a provider is paid for each service, supply, or equipment. Traditional indemnity plans are fee for service plans.
Formulary
List of approved prescription medications for which a health care plan will pay. Medications that are not listed in the formulary will not be covered or may only be covered under special circumstances.
Gatekeeper
A professional designated by the health care plan who decides what services will be provided by the health plan. The gatekeeper is usually your designated primary care provider (PCP). The gatekeeper is responsible for referrals and coordination of care.
Health Maintenance Organization (HMO)
A system of organizing many health care providers within a single structure or network to control costs by careful monitoring of services received, providers used, and fees charged.
Indemnity Plan
Traditional insurance plan that insures against hurt, loss, or damage.
Individualized Education Plan (IEP)
A contract for special education services signed by the parent and school staff. It is a personalized curriculum that incorporates the student's needs, interests, and abilities. The plan is developed with input from both the child's family and school personnel. It includes teaching goals and strategies, targeted student behaviors, and evaluation criteria. The plan should be reviewed frequently and updated as needed.
Individualized Family Service Plans (IFSP)
A plan developed jointly by a team of early intervention professionals and parents to address the needs of a disabled child (0 to 3 years old). The IFSP must include goals and objectives, identify resources, outline steps to be taken to reach stated objectives, and identify a service coordinator.
Insured
The person who is covered under an insurance policy.
Insurer
The insurance company or any other organization which assumes the risk and provides the policy to the insured.
Lifetime Maximum
The total amount that an insurance policy will pay out for medical care during the lifetime of the insured person.
Managed Care
A system of health care in which physicians and health insurance companies form a network to control costs by careful monitoring of services, providers, and fees. There are three types of managed care plans: HMO, PPO, and POS.
Medicaid
Programs of public assistance to persons, regardless of age, whose income and resources are insufficient to pay for health care. These programs are administered by individual states.
Medically Necessary
A term used in insurance policies to determine eligibility for health benefits and services. Insurance companies limit coverage to services they consider medically necessary. It is very important to identify how your plan defines this term. The definition may be included in your policy. If not, ask in writing for information on how the company determines medical necessity.
Medicare
The federal insurance system for disabled and aged persons.
Mental Retardation
Below average intellectual functioning (IQ is less than 70) causing impairment in the individual's ability to adapt to the environment. Mental retardation is caused by an injury, disease, or abnormality that existed before age 18. The most common presentation of mental retardation is the failure to achieve age-appropriate developmental skills.
Neuromotor Impairments
Problems associated with muscle weakness, abnormal muscle tone, neuromuscular control, and coordination.
Neuropsychological Evaluation
Evaluation performed by a neuropsychologist to determine how the brain injury has affected the child's behavior and ability to function in a classroom and to learn new information. The evaluation may be conducted by visiting the school and observing the student, or it may be performed by conducting tests in short sessions.
New Hampshire Healthy Kids
A partnership between the Department of Health and Human Services and the New Hampshire Healthy Kids Corporation that provides free and low-cost health coverage to uninsured New Hampshire children.
Open Enrollment Period
A period when you may sign up for a health insurance plan or make changes in your insurance without waiting periods or consideration for pre-existing conditions. Many employers offer these periods yearly. You may also be offered an open enrollment opportunity to join a health insurance plan when you begin a new job.
Out-of-Pocket Costs
All the health expenses that you pay yourself, including deductibles, co-payments, and charges not covered by any health plan.
Out-Patient Services
Therapeutic services provided to a patient residing outside the hospital but returning on a regular basis to receive services.
Point-Of-Service (POS)
This is a type of managed care plan. Subscribers must have a primary care doctor who is a member of the POS network. Subscribers are given incentives to use providers within the network, but may use providers outside the network for greater out-of-pocket costs.
Policy
The legal document issued by the company to the policyholder which outlines the conditions and terms of the insurance.
Policyholder
One who owns an insurance policy.
Pre-existing Condition
A condition that has been medically treated or would normally have been medically treated before enrollment in a medical insurance plan. In some cases, pre-existing conditions exclude a person completely from buying health insurance. In other cases, the insurance company may charge higher premiums for the individual. They may also offer the insurance, but refuse to cover any treatment relating to the specific condition. This may change with federal and state legislation, so keep up to date on the law.
Preferred Provider Organizations (PPO)
This is one type of managed care plan. Subscribers must have a primary care doctor who is a member of the PPO; however, they may see other network physicians without referral by the primary care physician. Subscribers are given incentives to use providers within the network; however they may use providers outside the network for greater out-of-pocket costs.
Presumptive Eligibility
An individual is presumed eligible from the time application is made and will receive health services while waiting for final eligibility approval.
Primary Care Provider
A physician or nurse practitioner who practices in the primary care fields of family medicine, general internal medicine, or general pediatrics. A primary care provider addresses the large majority of an individual's health care needs, develops a sustained relationship with the patient, and practices in the context of family and community. Primary care is often practiced in an out-patient setting.
Prolonged Illness Clause or Extended Benefits
A possible option in your coverage for 100% reimbursement (instead of partial) for all services relating to your child's condition. This option may also add to your child's lifetime maximum. Inquire if this kind of clause is part of your plan and how you can apply for it.
Providers
Physicians and other health care professionals and organizations.
Rider
A legal document added to an insurance plan that either restricts or adds coverage. States may have regulations about riders.
Seizure Disorder
Repeated occurrence of seizures sometimes referred to as epilepsy. Some seizures are unusual twitching or shaking of the body. Other types of seizures include vacant or blank staring and lack of response to voice or touch. Seizures are caused by abnormal brain activity and are common in severely brain injured people.
Speech and Language Impairment
Problems associated with language skills, speech, and oral and pharyngeal sensorimotor function.
Stop-Loss
A clause that limits your liability to a specified amount on medical expenses covered by your health insurance. After expenses reach that amount, the insurance company pays all of your remaining covered medical expenses for the year, including deductibles and co-payments.
Vocational Assessments
A process that utilizes work, real or simulated, and educational services as a means to help individuals identify vocational abilities.
Vocational Program
A program that offers employment planning. It may include vocational evaluation, skill training, work adjustment, job training, job placement, job coaching, and sheltered and/or supported employment.
Waiting Period
The length of time an individual must wait from the date he or she applies for insurance coverage to the date that the insurance policy is effective.
Wrap-Around Policy
A supplementary insurance plan designed to pay for additional health benefits not covered by another plan. A wrap-around policy can provide more comprehensive benefits for a child with extensive medical needs.