Accelerated death benefit (ADB) Show This can help people who have a fatal illness. The member or spouse can get some life insurance benefits as an early payment. Accidental death and dismemberment (AD&D) This benefit can be paid in two ways. It can be paid to the insured person after an accidental injury. Or it can be paid to someone else after the death of an insured person. Accidental death and personal loss (AD&PL) or AD&D Ultra® This benefit covers the same losses as AD&D. It also pays for other unexpected events. Such events could cause loss of sight, speech or hearing. In case of death, benefits may be used for education, child care and other services. Accountable care organization (ACO) It is a group of doctors, hospitals and other health care providers. They work together to coordinate patient care. They are responsible for:
Accreditation This is proof that a health plan or hospital meets certain standards. An outside group decides this through an official review. Active full-time employee This is a person who works a normal workweek for an employer. Employees must work at least the number of hours shown in a plan's Schedule of Insurance. ADA Also known as the Americans with Disabilities Act. This law protects the rights of people with disabilities. It helps prevent them from being treated unfairly on the job. ADB Also known as accelerated death benefit. This can help people who have a fatal illness. The member or spouse can get some life insurance benefits as an early payment. AD&D Also known as accidental death and dismemberment. This benefit can be paid in two ways. It can be paid to the insured person after an accidental injury. Or, it can be paid to someone else after the death of an insured person. ADEA Also known as Age Discrimination Employment Act. This is a U.S. law. It protects people against unfair treatment in the workplace due to age. Adjudication This is the way health plans decide how much they will pay for certain expenses. Adjusted pre-disability earnings A long-term disability plan provides a source of income if you cannot work because of illness or injury. This helps you maintain a percentage of what you earned before you became disabled. Adjustments are made over time to help protect against inflation. Example: A disability plan pays 60% of your salary. You earned $SOK before you become disabled at age 40. With no adjustment to your income, inflation would greatly reduce your buying power by the time you reached age 60. AD&PL Also known as accidental death and personal loss coverage. This benefit covers the same losses as AD&D. It also pays for other unexpected events. Such events could cause loss of sight, speech or hearing. In case of death, benefits may be used for education, child care and other services. Advance directive This legal document tells your doctor what kind of care you want or do not want. It will be used if you are too sick to make medical decisions on your own. It is sometimes also called a living will. Aetna Health app The Aetna Health® app helps you get the most out of your health plan and benefits by providing easy-to-navigate information and seamlessly connecting you to care. Learn more and download the Aetna Health® app today on the App Store and Google Play. Aetna HealthFund® This is the name used for Aetna's consumer-directed health products. Each one comes with different types of funds to help members pay for their care. These funds are health reimbursement arrangement (HRA), health savings account (HSA), retiree reimbursement account (RRA), flexible spending account (FSA) and first dollar plan. Aetna member website Take charge of your health plan with the Aetna member website. Get all the plan information you need and find tools to help you manage your benefits. Register and log in today. Affordable Care Act (ACA) The comprehensive health care reform law enacted in March 2010. Age Discrimination Employment Act (ADEA) This is a U.S. law. It protects people against unfair treatment in the workplace due to age. Alcohol and drug restriction or limitation This limits the length of time benefits will be paid. It applies to treatment for disabilities due to alcohol or drug abuse.
Allowable expense(s) This is the part of a bill that is eligible to be paid under your health plan. Allowed amount A limit on the amount your health plan will pay. Also called the recognized charge. If you choose to go out of network, your provider may not accept this amount as payment in full and may bill you for the rest. This is in addition to your plan's required copays and deductibles. Check your plan documents for more details: Your health plan documents will tell you how we pay for out-of-network care and how we calculate the allowed amount. Or call Member Services at the phone number listed on your Aetna ID card. Ambulatory care Also known as outpatient care. This is care a person gets in a clinic, emergency room, hospital or surgery center. The person gets the care and goes home. There is no overnight stay. Ambulatory surgery Also known as an outpatient procedure. Some procedures can be done in a hospital, surgery center or doctor's office. The person gets it done and goes home. There is no overnight stay. Americans with Disabilities Act (ADA) This law protects the rights of people with disabilities. It helps prevent them from being treated unfairly on the job. Ancillary services These are services provided to support your health care. Some examples include X-rays or lab tests. Annual coordinated election period (AEP) This is a time when you can make changes to your Medicare plan. Any occupation This is any type of job for which a person is qualified. A person can do the job because of schooling, training or experience. Appeals process This process lets you ask for a review of claims that have been denied by your health plan. Authorization* This is an important process. It is approval a person gets for care before receiving care. This helps people know if the care is covered by a health plan. People should check with their plan to see what kind of service needs this approval. This can also be called:
*In Texas, this approval is known as a pre-service utilization review and is not verification as defined by Texas law. Qualified medical expenses (also known as eligible medical expenses) These are costs paid for health care that people can deduct from their taxes. To do so, they must not have received payment for the expense through insurance. Qualifying event These are events that let members change their health benefits. Examples include death, job loss, divorce and marriage. X-ray This is a picture that can show bones and other internal parts of the body. It is used to help diagnose certain conditions. Balance billing Doctors or hospitals sometimes do this. They bill patients to make up the difference between their usual fee and the amount they are paid by the health plan. Doctors and hospitals that work with Aetna will not do this. Bariatric surgery This is weight-loss surgery. It is for very overweight people who haven't lost weight with diet and exercise. Doctors perform two types. One makes the stomach smaller. The other bypasses part of the intestine. Balance billing (Medicare) Doctors or hospitals that do not charge the fees that Medicare approves sometimes do this. They bill patients to make up the difference between the approved fee and the top amount allowed by Medicare. The top amount is 15 percent more than the approved fee. Doctors and hospitals that work with Aetna will not do this. Behavioral health This is also called mental health. It describes a person's state of mind. Depression, eating disorders and substance abuse are conditions that fall under this term. Beneficiary This is the person you choose to receive your assets if you die. It can be the person you choose to receive payment from a life insurance policy after your death. It also applies to other types of insurance, such as AD&D. Beneficiary (Medicare) This is someone who has a health plan under Medicare. Benefit This refers to medical services covered by your health plan. This word is also used to describe your health plan in general. It can also mean payment received under a plan. Benefit duration This is the length of time that benefits will be paid. It applies to workers who are out on short-term or long-term disability. Benefit maximum This is the maximum amount that may be paid under a benefit plan. There are several types of benefit maximums. Benefit period A period of consecutive days during which medical benefits for covered services are available to the plan member. Board certified This describes health care practitioners who have met national standards for knowledge, skills and experience in a specialty area. These practitioners include doctors, physician assistants, dentists, pharmacists and nurses. Brand-name drug A drug sold by a drug company under a specific name or trademark. Brand-name drugs may be available by prescription or over the counter. Broker Insurance brokers are also called agents. They are licensed by states as agents, brokers or insurance producers. Insurance brokers help a person or business buy an insurance plan. The insurance plan can be bought through a health insurance exchange. Or it can be bought directly from an insurer. Brokers represent the person or business buying insurance. However, they are usually paid by a commission from the insurer. Bronze health plan See "Health plan categories." Capitation This is a fixed amount of money doctors and hospitals get from health plans to serve plan members. They get this amount no matter how many patients they see. Case management This is the way health plans help people with complex care needs. Case managers help coordinate care to help people improve their health. Centers for Medicare & Medicaid Services (CMS) This is a federal agency. It runs the Medicare program. It also works with states to run the Medicaid program. Certificate of coverage This details the benefits provided by your health plan. It lists what is covered and what is not covered. You will get this document after you sign up for a plan. Certification* This is an important process. It is approval a person gets for care before receiving the care. This helps people know if the care is covered by a health plan. People should check with their plan to see what kind of service needs this approval. This can also be called:
*In Texas, this approval is known as pre-service utilization review and is not verification as defined by Texas law. Certification of a period of disability This is a way to decide if a worker is truly disabled. The terms of the policy are used to decide this. Chemotherapy This is a cancer treatment. It involves chemical or biological drugs. These drugs are usually given through a vein. Chiropractic care This therapy is used to help treat the spine, joint pain and movement problems. A licensed chiropractor gives this care. Clinical policy bulletins (CPBs) Health insurers use these documents to explain the basis for coverage decisions for their members. In them, you can find details about how services are covered, or not covered. You can also find special guidelines that you may have to meet for a service to be covered. Insurers use objective sources to make these decisions, like expert opinions or scientific literature. You may hear other terms that mean the same thing as CPBs. One example is "coverage determination guidelines." Another is "medical coverage guidelines." Claim This is a request to be paid by a health plan for health services given. An example would be the claim your doctor sends to your health plan for an office visit. It is also a request for payment under a disability or life insurance plan. Closed formulary A formulary is a list of prescription drugs the health plan covers. If the plan has a closed formulary, it only covers drugs that are on that list. It will not cover any part of the cost of non-formulary drugs. However, in some instances, a plan may be willing to make an exception. To get one, you need to contact the plan and tell them why the drug is needed. CMS Also known as Centers for Medicare & Medicaid Services. This is a federal agency. It runs the Medicare program. It also works with states to run the Medicaid program. COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986) COBRA is the continuation of coverage law. It requires most group health plans to offer a temporary continuation of group health coverage in certain circumstances. COBRA covers eligible employees, their spouses, former spouses and dependent children. If elected, it enables them to keep their coverage when it would otherwise be lost due to:
Coinsurance This is the percentage of health care expenses you pay after your deductible. Your health plan pays the rest up to any benefit or lifetime maximum. COLA Also known as cost of living adjustment. This is an optional benefit. It goes with some long-term disability plans. It raises the monthly benefit amount each year. The person on disability gets more money based on the cost of living. These raises are given only for a set time period. Combined life insurance maximum This is the highest amount of life insurance you can get. It means you can have both basic and supplemental plans, but only up to this amount. Common-law marriage This is when two people live together for a certain amount of time. They think of themselves as married because of the time spent together. Some states agree and recognize them as married. Complication of pregnancy This is a health problem that happens during pregnancy. It is something that would not happen in a normal pregnancy. It can affect the baby, the mother or both. Composite This is a type of filling that matches your natural tooth color. Congenitally missing teeth These are teeth that never existed in your mouth. This is a condition that existed at, or dates from, your birth. Consumer-directed health plan This plan helps you control more of your health benefit dollars. It includes a fund or account that can be used to pay for your medical expenses. Most health funds allow unused dollars to be rolled over from year to year, for as long as you stay in the plan. Some plans allow the fund to go with you, even if you change jobs. Consumerism This is a term for a new movement in health care. Its goal is to have everyone more involved in their own care. This means people will have more information to make better decisions about their health care. It includes knowing the real costs of health care and taking an active role in managing those costs. Contract (also known as a benefit certificate or policy) This is a legal agreement. It is between a customer (an individual or group) and an insurance plan. It lists all details of the plan's coverage. Contract holder This is a legal term. It is a customer (an individual or group) who buys an insurance plan from an insurer. Contributory This refers to a group health plan. It means costs are shared between an employer and its employees. Conversion charge This is an amount charged to change policies. It must be paid when you change a group health plan to an individual policy. Conversion option This means people can buy a policy on their own after they leave a group plan. It may be offered with certain health and life insurance plans. It is often another choice besides COBRA coverage for health plans. Coordination of benefits (COB) These rules are used to decide which plan pays first for people who have more than one plan. This helps coordinate coverage and allows claim information to be shared by the plans. This way, the plans can avoid duplicate payments. Copay This is the dollar amount you pay for health care expenses. In most plans, you pay this after you meet your deductible limit. For example, you pay a set dollar amount to your doctor for an office visit. So, if your copay is $25, you pay that amount when you go to your doctor. Copays are also used for some hospital outpatient care services in the original Medicare plan. In prescription drug plans, it is the amount you pay for covered drugs. Copayment Also known as copay. This is the dollar amount you pay for health care expenses. In most plans, you pay this after you meet your deductible limit. For example, you pay a set dollar amount to your doctor for an office visit. So, if your copay is $25, you pay that amount when you go to your doctor. Copays are also used for some hospital outpatient care services in the original Medicare plan. In prescription drug plans, it is the amount you pay for covered drugs. Cost Estimator This online tool makes it easy to compare costs for office visits, procedures and more at different doctors and hospitals. The estimates are based on your health plan. The tool factors in your deductible, coinsurance and copays. And it shows what Aetna will pay. Cost of living adjustment (COLA) This is an optional benefit. It goes with some long-term disability plans. It raises the monthly benefit amount each year. The person on disability gets more money based on the cost of living. These raises are given only for a set time period. Coverage gap This is also called the donut hole. It is the part of the Medicare plan where the member pays for prescription drugs. The plan does not pay. The gap occurs after you reach your initial coverage limit. It lasts until the expenses you pay add up to a certain amount. Covered services (also covered benefits or covered expenses) These are services or supplies your health plan covers. They are eligible to be paid by your plan. Credentialing This is a process. It is used to be sure doctors and hospitals meet certain standards. It is also used for other health professionals and facilities. Creditable coverage Also known as prior creditable coverage. This term means types of health coverage a person has had. People sometimes need to prove they have had this so they can be fully covered by a new plan. Some examples of acceptable types are:
Creditable coverage - Medicare This applies to people who are eligible for Medicare. It is coverage that is at least as good as the Medicare drug plan. If you have such a prescription drug plan, you can stay in your plan. You will not be charged higher fees if you switch to Medicare later. Custodial care This is care that helps people with daily life activities. The person giving the care does not have to be trained in medicine. This care may help people with walking, bathing, dressing and eating. Customary and reasonable A limit on the amount your health plan will pay. Also called usual, customary and reasonable (UCR), reasonable, or prevailing charge. The limit is based on data Aetna receives. The data is based on what doctors charge for the health care service. We receive this data from Fair Health, an independent organization. Check your plan documents for more details: Your health plan documents will tell you how we pay for out-of-network care. Or call Member Services at the phone number listed on your Aetna ID card. Date claim incurred (DCI) This is for disability plans. It is the date a person becomes disabled. Date claim received This is the date the insurance company receives the claim. Date last worked (DLW) This is the last day a person worked before becoming disabled. For long-term disability, it is the last day the person worked part of a day. For shortterm disability, it is the last day a person worked half a day or more. Date of disability (also known as date of claim or incurred date) This is the date a person becomes disabled. The person must meet the plan definition of disabled. Day treatment center This is a place where people can get mental health care. They don't stay overnight. They visit the treatment provider as needed for care. DCI Also known as date claim incurred. This is for disability plans. It is the date a person becomes disabled. Death benefit (also known as face amount) This applies to life insurance. It is the money that an insurance company pays when an insured member dies. Deductible The amount you pay for covered services before your health plan begins to pay. Deductible (Medicare) This is what you must pay for health care before the Medicare plan begins to pay. This amount can change each year. Defined contribution plans There are many different types of these plans. In them, employers give each worker a fixed amount of money. The worker can use the money for retirement, health or some other benefit. When the plan is for health benefits, the money can be used to pay for health insurance or health services. Dependent This is a person who is covered by another person's plan. It can be a child, spouse or domestic partner. Dependent care reimbursement account You can put money into this account before taxes are taken. You can use the money later to pay for eligible childcare expenses. No taxes are taken out, so you lower your taxable income rate. The money does not build interest. It cannot be rolled over to the next year. Also, the money cannot be taken from one job to another. Diagnostic tests These are tests that a health care professional orders. The tests help see if a person has a condition or a disease. X-rays and ultrasounds are examples of these tests. Direct access (also open access) This is a type of health plan. The plan lets you go directly to a health care professional in the plan's network without a referral. Disability There are two types of disability: Long-term disability (LTD): Employees may have an illness or injury. They may not be able to work for a long time. An LTD benefit through their employer helps protect them and their families from financial loss. It provides a source of income for a set time. This helps to maintain a percentage of the employees' pre-disability income. Other income benefits outside the LTD plan may reduce the amount payable under an LTD plan. See "Other income benefits." Short-term disability: This pays part of workers' pay when they are out of work. They must be out of work for a short time with an illness or injury that is not related to work. Disability and absence management These are services and products. They help businesses track and manage when workers are out. This includes general absences and leaves of absence. Disability payment This is the money paid to a member who is disabled. Disease management This is a type of program that comes with some health plans. It is used to help people who live with a chronic illness. It helps members manage their health and prevent future problems. DLW Also known as date last worked. This is the last day a person worked before becoming disabled. For long-term disability, it is the last day the person worked part of a day. For short-term disability, it is the last day a person worked half a day or more. DME Also known as durable medical equipment. This is equipment a person needs that is:
Examples are a wheelchair or hospital bed used in the home. For Medicare patients: These are devices that doctors order for use in the home. They must be reusable. Some examples are walkers, wheelchairs or hospital beds. They are covered under Medicare Part A and Part B for home health services. Domestic partners This means two people who live together but are not married. They are responsible for each other's well-being and finances. They may or may not be a same-sex couple. Donut hole (Medicare) Also known as coverage gap. It is the part of the Medicare plan where the member pays for prescription drugs. The plan does not pay. The gap occurs after you reach your initial coverage limit. It lasts until the expenses you pay add up to a certain amount. Drug This is a natural or man-made substance used to treat an illness. Drug formulary Also known as a formulary. This is a list of prescription drugs the health plan covers. It can include drugs that are brand name and generic. Drugs on this list may cost less than drugs not on the list. How much a plan covers may vary from drug to drug. An open formulary provides a greater choice of covered drugs. It is also called a preferred drug list. Drug tiers These are groups of different drugs. Usually, the plans group the drugs by price. Each group or tier requires a different copay. You might see the groups listed as generic, brand-name, or preferred brand-name drugs. Generic drugs often have lower copays. Brand-name drugs have higher copays. Dual eligibles (Medicare) These are people who can get benefits through two plans: Medicare and Medicaid. Duplicate coverage This is when you and your dependents have the same coverage through two or more health plans. Durable medical equipment (DME) This is equipment a person needs that is:
Examples are a wheelchair or hospital bed used in the home. Durable medical equipment (DME) (Medicare) These are devices that doctors order for use in the home. They must be reusable. Some examples are walkers, wheelchairs or hospital beds. They are covered under Medicare Part A and Part B for home health. EAP Also known as employee assistance program. This can help people balance work and life issues. It gives support and counseling to help people deal with stress, family issues and more. The program is for employees, their dependents and household members. Employers buy it. Workers do not pay to use an EAP. Earnings definition This is the base pay for calculating disability benefits. The benefits could be short- or long-term. The pay does not include bonuses, overtime or other extra pay. Some types of pay, like commissions, may be offered. It depends on the policy. Effective date This is the date your health plan becomes active. Your coverage starts on this day. Eligibility This includes terms that decide who can get coverage. The requirements vary. They could include health conditions, how long a person is employed, job status and more. Elimination period This is the amount of time people must be disabled before they can get long-term disability benefits. The policy states how long the time is. No benefit is payable for or during this period. Emergency This is a serious illness or injury. It comes on suddenly. It is something that needs immediate medical care. If a person does not get care quickly, death or serious health problems may occur. Emergency facility This is a place that offers short-term care on the spot. People usually go to one when they have a sudden illness or injury. Two examples are hospitals and clinics. Employee assistance program (EAP) This can help people balance work and life issues. It gives support and counseling to help people deal with stress, family issues and more. The program is for employees, their dependents and household members. Employers buy it. Workers do not pay to use an EAP. Employee Retirement Income Security Act of 1974 (ERISA) This is a law. It controls employer-based health plans. It also sets rules for pensions and other benefits plans. Electronic health record (EHR) This is a digital version of a patient's medical history. The goal is that all professionals involved in a patient's care enter details into this record. That could be your primary doctor or specialist. Or pharmacies, hospitals and labs. The EHR might include details like medicine taken, lab results and vital signs. Patient information can now be easily seen and shared across all providers. So there's a broader view of a patient's health. Enrollee Also known as a member. A member is someone who belongs to a health plan. Sometimes a member is known as an enrollee. Enrollment period (Medicare) This is when people can sign up for a Medicare health plan. At this time, the plan accepts people new to Medicare. The plan must also allow all eligible people with a different Medicare plan to join. Emergency medical transportation Local transportation in a specially equipped certified vehicle from the scene of an accident or a medical emergency to the closest facility that can provide the necessary care. Emergency services With respect to an emergency medical condition, a medical screening examination that is within the capability of the emergency department of a hospital and within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required to stabilize the patient.
EOB See "Explanation of Benefits." This is a statement a health plan sends to a health plan member. It shows charges, payments and any balances owed. It may be sent by mail or e-mail. EOI See "Evidence of insurability." Ergonomic evaluation This looks at a person's physical work space. The goal is to make sure it is safe and comfortable. It's important that the equipment a worker uses gives proper support. Doing this helps lower the risk of work-related injuries. Ergonomics This is an applied science. It calls for creating a physical work setting that fits and supports the worker. The idea is to help workers be physically safe and comfortable. This is important to workers' health while they do daily tasks. It could mean having the right chair, keyboard or desk, or a headset if a worker has to be on the telephone a lot. ERISA Also known as the Employee Retirement Income Security Act of 1974. This is a law. It controls employer-based health plans. It also sets rules for pensions and other benefits plans. Essential health benefits This refers to a set of health care service categories. The Affordable Care Act requires that these categories be covered by certain plans in the individual and small group markets. The categories include:
Only plans that cover these benefits can be certified and offered in the health insurance marketplace. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid. Evidence-based medicine This is when doctors use the latest research findings to help them make decisions on patient care. They combine it with their own expertise and what they learn from the patient. Evidence of insurability (EOI, also known as medical underwriting) A group or individual might have to go through this process when applying for health or life insurance. EOI may also be needed when someone wants more coverage or is enrolling late. It helps the insurer decide whether to cover the person or group. The process might include:
Exchange See "Health insurance marketplace." Exclusions These are conditions or services that the health plan does not cover. Experimental services or procedures These are often newer drugs, treatments or tests. They are not yet accepted by doctors or by insurance plans as standard treatment. They may not be proven as effective or safe for most people.
Explanation of Benefits (EOB) This is a statement a health plan sends to a health plan member. It shows charges, payments and any balances owed. It may be sent by mail or e-mail. Face amount Also known as a death benefit. This applies to life insurance. It is the money that an insurance company pays when an insured member dies. Facility-of-payment provision This can be part of a life insurance policy. It lets insurers pay out some of the benefit before the final claim is settled. The money can go to a beneficiary. It can also go to a friend or relative. The money is often used to pay for funeral costs or other related costs. Family and Medical Leave Act (FMLA) This is a law for employers with 50 or more workers. It applies to workers who need to take time off from work for:
Workers can get up to 12 workweeks of unpaid leave per year if they qualify. This law also provides certain rights for members of the military and their families. Federal Employees Health Benefits Program (FEHBP) This is a type of health plan. Most federal government workers are covered under it. Federal poverty level (FPL) A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine eligibility for certain programs and benefits.
Federally qualified health center (FQHC) These are federally funded nonprofit health centers or clinics. They serve medically underserved areas and populations. They provide primary care services. The amount they charge is based on the person's ability to pay. Fee for service This is a process used by some health plans. It lets plans pay doctors and other providers a fee for each service they provide. FEHBP Also known as Federal Employees Health Benefits Program. This is a type of health plan. Most federal government workers are covered under it. Flexible spending account (FSA) This is a way workers can set aside money to help pay for health care. An FSA is used with a health benefits plan. Workers ask for money to be taken from their pay each pay period. This money is not taxed in most states. The money goes into a fund the worker can use to pay for different health expenses. All money must be used by the end of the stated year or it will be lost. This money cannot be transferred to another job or account. FMLA Also known as the Family and Medical Leave Act. This is a law for employers with 50 or more workers. It applies to workers who need to take time off from work for:
Workers can get up to 12 workweeks of unpaid leave per year if they qualify. This law also provides certain rights for members of the military and their families. Formulary This is a list of prescription drugs the health plan covers. It can include drugs that are brand name and generic. Drugs on this list may cost less than drugs not on the list. How much a plan covers may vary from drug to drug. An open formulary provides a greater choice of covered drugs. It is also called a preferred drug list. Formulary exclusion list This is a list of prescription drugs not covered by a health plan. It applies to closed formulary plans. If a member needs a drug on this list, the doctor must ask the plan to cover it as an exception. The plan will only do so if use is medically necessary. FSA See "Flexible spending account." Fully insured employers These employers pay the health plan provider to administer and manage the benefits they've chosen. The insurer pays the claims. This means the insurer is the one taking the risk. Functional capacity evaluation This exam is done by occupational or physical therapists. It tests people who have been injured or sick to see if they can return to work. It might test how well a person can lift, bend, stand, climb or carry. It can also focus on a specific function, like use of the hands. The tests used show if the worker can resume normal job activities. Generic drug A generic drug is a copy of a brand-name drug that no longer has a patent. The cost is usually less than the brand-name drug. Gold health plan See "Health plan categories." Grievance A written or oral complaint submitted by or on behalf of a covered person regarding: a) availability, delivery or quality of health care services; b) claims payment, handling or reimbursement for health care services; or c) matters pertaining to the contractual relationship between a covered person and a health carrier. Group coverage This is a plan offered by a plan sponsor to an employee group or other group. The plans offer health, dental, life insurance coverage and more. Group plans may also be offered to retirees. Group insurance Also known as group coverage. This is a plan offered by a plan sponsor to an employee group or other group. The plans offer health, dental, life insurance coverage and more. Group plans may also be offered to retirees. Group universal life (GUL) This is a life insurance product. It offers a death benefit. It also lets members build up a fund that helps them save on taxes. If members leave the group or retire, they can take their coverage with them. Guarantee issue maximum This applies to life insurance plans. It is the dollar amount a person may qualify for without proof of good health. GUL Also known as group universal life. This applies to life insurance plans. It is the dollar amount a person may qualify for without proof of good health. Habilitation services Occupational therapy, physical therapy, speech therapy and other services prescribed by a Physician pursuant to a treatment plan to enhance the ability of a child to function with a congenital, genetic or early acquired disorder, including but not limited to health care services that help a person keep, learn, or improve skills and functioning for daily living. HDHP Also known as high-deductible health plan. This health plan has to meet federal rules. This is so members can put money into a health savings account or health reimbursement arrangement. These funds can help pay for health care. The plan deductible is higher than a standard health plan. Premiums are lower. Health assessment A health assessment is a form or on line tool to help you find out how healthy you are. It also helps you see if you are at risk for future illnesses. It gathers information by asking a series of questions. It may be used to help decide which health programs would be good for you. Health benefits plan This is any plan that helps pay for health care services. There are many types of plans. Some are limited to certain types of services. Some plans cover only hospitalizations, for example. Some plans offer open access to doctors. Some offer access to network doctors only.
Health care consumerism Also known as consumerism. This is a term for a new movement in health care. Its goal is to have everyone more involved in their own care. This means people will have more information to make better decisions about their health care. It includes knowing the real costs of health care and taking an active role in managing those costs. Health fund This is an account set up to help members pay for health care costs. In some funds, money is put into the fund for them. In others, they can put money in on their own. Some funds do both. There are also plans with the Aetna Health Fund®. Health insurance carrier This is a company that provides health insurance plans. Health insurance marketplace A resource where individuals, families and small businesses can:
The marketplace also provides information on programs that help people with limited ability pay for coverage. This includes:
The marketplace encourages competition among private health plans. It is accessible through websites, call centers and in-person assistance. Health Insurance Portability and Accountability Act (HIPAA) This is a federal law. It limits the rules a group health plan can place on benefits for pre-existing health problems. It gives people access to quality health care coverage when they switch jobs. This law does not let group health plans charge a higher rate because of a person’s prior health status. It can also limit rules on some individual health plans. The law also helps protect private health information. It sets national standards for handling private health records. Health maintenance organization (HMO) This is a health plan that arranges health care services for its members. In most HMO plans, members choose a primary care physician (PCP). The PCP is from the health plan's provider network. The PCP gives routine care and refers members to network doctors if special care is needed. Health maintenance organization (HMO) (Medicare) This is a type of health plan. The plan has a network of doctors and hospitals that help coordinate your care. This lets you get more benefits than you would with the original Medicare plan. It also gives you more benefits than many Medicare supplemental plans. Health plan categories Plans in the health insurance marketplace are primarily offered in four health plan categories - Bronze, Silver, Gold, or Platinum. The categories determine the percentage of health care costs the plan covers. The plan category affects the total amount you'll spend on health benefits. The percentages the plans will spend, on average, are:
This is not the same as coinsurance. Coinsurance is when you pay a specific percentage of the cost of a specific service. Health reimbursement arrangement (HRA) This is a part of a health plan that lets members use a fund to pay health care costs. The member's employer puts money into a fund. Members can use the fund to pay deductibles, coinsurance and other covered health care costs. Unused money can usually be rolled over and used in the next plan year. Health savings account (HSA) This is a part of a health plan. You can put money into this account. You can use it to pay for covered health care costs. Or you can save money in it for future health care costs. The account grows interest. You can take your account with you if you leave your job. You must be covered by a highdeductible health plan to qualify for an HSA. High-deductible health plan (HDHP) This health plan has to meet federal rules. This is so members can put money into a health savings account or health reimbursement arrangement. These funds can help pay for health care. The plan deductible is higher than a standard health plan. Premiums are lower. HIPAA Also known as the Health Insurance Portability and Accountability Act. This is a federal law. It limits the rules a group health plan can place on benefits for pre-existing health problems. It was passed to give people access to quality health care coverage when they switch jobs. This law does not let group health plans charge higher rates because of a person's prior health status. It can also limit rules on some individual health plans. The law also helps protect private health information. It sets national standards for handling private health records. HMO Also known as health maintenance organization. This is a health plan that arranges health care services for its members. In most HMO plans, members choose a primary care physician (PCP). The PCP is from the health plan's provider network. The PCP gives routine care and refers members to network doctors if special care is needed. Home health care Home health care means health care services a patient receives at home. It is often offered after a hospital stay. Coverage depends on the patient's needs and health plan. Home infusion therapy This is a type of medical treatment offered in a patient's home. The patient gets medicine through a vein. Nutrients and fluids may also be given this way. Hospice This is a type of nursing and supportive care for patients who are ill and near death. This care can occur in a facility or at home. Hospital This is a place that offers medical care. Patients can stay overnight for care. Or they can be treated and leave the same day. All hospitals must meet set standards of care. They can offer general or acute care. They can also offer service in one area, like rehabilitation. HRA Also known as health reimbursement arrangement. This is a part of a health plan that lets members use a fund to pay health care costs. The member's employer puts money into a fund. Members can use the fund to pay deductibles, coinsurance and other covered health care costs. Unused money can usually be rolled over and used in the next plan year. HSA Also known as health savings account. This is a part of a health plan. You can put money into this account. You can use it to pay for covered health care costs. Or, you can save money in it for future health care costs. The account grows interest. You can take your account with you if you leave your job. You must be covered by a high-deductible health plan to qualify for an HSA. ID card This is the card members get when they join a health plan. It helps doctors and other health care providers know what coverage a patient has. It shows the member's assigned plan number and plan contact information. Members should show the card at every health care visit. Indemnity plan This is a type of health plan. Members can get care from any licensed doctor or hospital. They get the same level of benefits no matter who they see. There is no network. The plan pays a percentage of each covered health care service. These plans often have deductibles, coinsurance and certain benefit maximums. This is also called a traditional plan. Independent medical exam This is needed to help decide on a disability claim. A doctor examines the person in question. This doctor has not treated the person before. Independent practice association (IPA) This is a group of doctors or other health care providers. They contract with one or more health plans to provide services. A member who sees a primary doctor in this group will be referred to specialists and hospitals in the same group. Members can go outside the group if the group can't handle their medical needs. Individual mandate This is also known as penalty, fine or individual responsibility payment. Beginning in 2014, the Affordable Care Act requires that most people have health insurance for themselves and their dependents. Those that do not may have to pay a penalty. Some people will be exempt from the mandate or the penalty. Others may be given financial help to pay for health insurance. Individual policy This is a health plan bought by a person who cannot get benefits through a group plan. Self-employed people often have to buy this type of plan. So do people who cannot get health benefits from their employer or other group. Individual retirement account (IRA) This is an account you can use to save for retirement. You can put in a certain amount of money each year. This amount can be deducted from the taxable income you report. Contributions and interest are not taxed until money is taken out. Infusion therapy This is a type of treatment that goes into a vein. It includes medicine or feedings. It can also deliver nutrients into the stomach by tube. Initial coverage limit This is the first part of a Medicare prescription drug plan. A member pays a set amount until the member and plan payments hit a certain total. Once this limit is reached, the terms change. Members may pay more as the plan moves to the coverage-gap phase. Initial enrollment period (IEP) This period lasts seven months. It centers on the event that qualifies you for Medicare - for example, your 65th birthday. It lasts the three months before, the month of, and three months after the event. Injectable drug This is a drug that is given with a needle or syringe. The medicine is put under the skin, into a muscle or into a vein. It may start as a powder that is mixed with water. In network This means we have a contract with that doctor or other health care provider. We negotiate reduced rates with them to help you save money. Your outof-pocket costs are lower when you stay in network. There are other benefits to using doctors in network. They will not bill you for the difference between their standard rates and the rate they've agreed to with us. All you have to pay is your coinsurance or copay, along with any deductible. And network doctors will handle any precertification your plan requires. Inpatient This is a person who has to stay in the hospital for care for at least one night. Inpatient care This is care given to a person who has been admitted to the hospital. This person will stay one or more nights. Insurance card Also known as ID card. This is the card members get when they join a health plan. It helps doctors and other health care providers know what coverage a patient has. It shows the member's assigned plan number and plan contact information. The card should be shown at every health care visit. Integrated health and disability (IHD) This program is for members who have health and disability coverage. It combines services from both plans. It gives members special help so they can return to work faster. lnvestigational services Also known as experimental services or procedures. These are often newer drugs, treatments or tests. They are not yet accepted by doctors or by insurance plans as standard treatment. They may not be proven as effective or safe for most people. IPA Also known as independent practice association. This is a group of doctors or other health care providers. They contract with one or more health plans to provide services. A member who sees a primary doctor in this group will be referred to specialists and hospitals in the same group. Members can go outside the group if the group can't handle their medical needs. IRA See individual retirement account. This is a health plan bought by a person who cannot get benefits through a group plan. Self-employed people often have to buy this type of plan. So do people who cannot get health benefits from their employer or other group. Lapse (or lapse in coverage) Anyone who buys an insurance plan pays a premium. You pay this amount every month. If you miss a payment, the insurance company can cancel your coverage. It means you have let your insurance coverage lapse. You have let it end. Late entrant (also known as late enrollee) There are certain times of the year when workers can choose or change benefits. The main time is called open enrollment. New employees can enroll when they first start. And those who get married or have a baby can make changes in their coverage when this change in their life occurs. Late entrants are:
Length of disability This is how long a person is certified as disabled. Length of stay This is the number of days a patient stays in the hospital for treatment. Days are counted in a row. Level amount schedule (also known as flat amount) This is a benefits schedule. It lists how much of a benefit each worker gets. All workers on it get the same benefit amount. There are different schedules for different types of workers. Life insurance Buying this means your loved ones can get money when you die. You may be able to choose the benefit amount. A premium must be paid to keep this policy active every year. You also choose a beneficiary. This is a person who you want to receive the money after your death. Employers may offer this as a benefit to their workers. You can also buy it on your own. There are many kinds of life insurance: term life, whole life, group universal life and others. Life threatening This means a condition is dangerous. You could lose your life. Do not wait to call a doctor. Lifetime maximum This is the total dollar amount of benefits you can receive. It can also be the total number of services you can receive. These totals are limits for a lifetime, not just for a plan year. Plans subject to federal health care reform can only have lifetime dollar maximums on non-essential benefits. Limitations These are restrictions that health plans place on coverage. They say what your plan does not cover.
Living will Also known as advance directive. This legal document tells your doctor what kind of care you want or do not want. Doctors use it when you are too sick to make medical decisions on your own. Long-term care insurance Long-term care services are costly. Health plans, disability insurance and Medicare do not help much. They are not made for this type of care. Long- term care insurance can help cover the cost of this care. Long-term care services These are personal care services. They help people who cannot care for themselves anymore. Services include help with bathing, dressing and eating. Services may involve constant supervision and care. This care may be given at home or adult day care centers. It can also be given at assisted living facilities and nursing homes. Long-term disability (LTD) Employees may have an illness or injury. They may not be able to work for a long time. An LTD benefit through their employer helps protect them and their families from financial loss. It provides a source of income for a set time. This helps to maintain a percentage of the employees' pre-disability income. Other income benefits outside the LTD plan may reduce the amount payable under an LTD plan. See "Other income benefits." Long-term disability (LTD) pension accrual This is for workers who will receive a pension when they retire. If they are disabled and cannot work for a long time, they might lose their full pension amount. This benefit pays into their pension even when they are disabled. It helps them get the full amount when they retire. Long-term disability (LTD) pension supplement This is for workers who will receive a pension when they retire. If they are disabled and cannot work for a long time, they might lose their full pension amount. This benefit adds a little extra to their pension fund payments at retirement. It makes up for what they lost while disabled. Look-back period This is used mostly in health plans people buy on their own. It is how far back a health insurance company will look at their health records. If the period is five years, people must list all conditions they had or were treated for in the last five years. If the list is wrong or has certain health problems on it, the company can say no. They can also say yes and call for a pre-existing condition waiting period. This is the time someone must wait before the condition will be covered. Disability plans also have look-back periods. They may exclude benefits for disabilities caused by pre-existing conditions. Lowest average wholesale price This is a reference price. It is the lowest cost that pharmacies, doctors and health plans might pay for a prescription drug on the market. Mail-order drugs Also known as maintenance medications. These are prescription drugs that people take on a regular basis. These drugs help treat chronic conditions. These drugs include ones for asthma, diabetes, high blood pressure and other health conditions. Buying them through a mail-order pharmacy can save money. Mail-order pharmacy People can get prescription drugs through the mail with this. It is a service that health plans often offer. Members can save time and money using it by getting a three-month supply all at once. CVS Caremark® Mail Service Pharmacy is the name of the mail-order pharmacy. Maintenance medications These are prescription drugs that people take on a regular basis. These drugs help treat chronic conditions. These drugs include ones for asthma, diabetes, high blood pressure and other health conditions. Buying them through a mail-order pharmacy can save money. Malignant This is a word to describe a tumor that shows signs of cancer. It can grow and spread in the body. See also "Metastatic (metastasize.)" Managed care This is a type of health plan. It is an agreement signed with doctors and hospitals to form a network. Members may get a higher level of benefits if they use doctors or hospitals in this network. Costs are often higher when people go out of the network for care. The plan may also require preapproval of some services. Managed care company This is a health insurance company. See also "Managed care." Mandated benefits These are the benefits that health care plans must provide. State or federal law requires them. MA plan This is a type of Medicare Advantage plan. It does not cover prescription drugs. MA-PD plan This is a type of Medicare Advantage plan. It covers prescription drugs. Marketplace See "Health insurance marketplace." Maximum benefit amount This is an amount of money that is paid to people through a disability plan or life insurance policy. It is the most that they can receive in one period. That could mean every week, every month, or once a year. The plan spells out how often this amount is paid. Maximum benefit period Some employers offer disability plans. These plans help people who cannot work because of illness or injury. The plan pays a part of their income for a time. This is the amount of time employees can receive a benefit amount through their disability plan. It is the longest period of time that they can collect this money. Maximum drug benefit This is a type of limit that some health plans have. It is the most the plan will pay for prescription drugs for a period of time. If a member's drug costs reach that limit within the time period, the plan will not cover the drug costs for the rest of that time. Medicaid Medicaid is a state government program. It provides health care coverage. It is meant for people with low incomes. This includes families and children. Medical emergency Also known as emergency. This is a serious illness or injury. It comes on suddenly. It is something that needs immediate medical care. If a person does not get care quickly, death or serious health problems may occur. Medical underwriting Also known as evidence of insurability. A group or individual might have to go through this process when applying for health or life insurance. It may also be needed when someone wants more coverage or is enrolling late. It helps the insurer decide whether to cover the person or group. The process might include:
See "Late enrollee." Medically necessary Also known as necessary. Health plans usually pay only for care that is necessary. They decide this by using medical standards or research that states what care is most effective. Care can mean health services or supplies. This also is called medically necessary, medically necessary services or medical necessity. Medicare This is a program of the federal government. It provides health care coverage. It is for people:
Medicare Advantage plan See "Medicare Part C." Medicare limiting charge This applies to a health care provider. The provider does not participate in Medicare. There is a limit on how much the provider can charge for a service covered by Medicare. The limit is 15% more than the amount Medicare allows for the service. Medicare Modernization Act This is a law. It:
Medicare Part A This is part of the original Medicare plan. It is managed by the federal government. It covers some, but not all, expenses for:
The plan has limits. People also must pay deductibles, copays and other costs. Medicare Part B This is part of the original Medicare plan managed by the federal government. People sign up for this plan. They usually pay a monthly premium for the plan. It covers:
It also pays some costs for some:
Medicare Part C This is a Medicare program. It is open to most people who have Medicare Part A and Medicare Part B plans. It provides medical and other benefits. These are provided through health plan companies approved by the federal government. The coverage is offered through Medicare Advantage (MA) plans. These plans can be:
When people use doctors and hospitals in the plans' networks, they might pay less. Some of these plans cover prescription drugs. That is an MA-PD plan. Some do not cover prescription drugs. That is an MA plan. Medicare Part D This is an optional Medicare plan. It provides coverage for some prescription drugs.
Medicare prescription drug plan This is an optional Medicare plan. It is separate from a Medicare health plan. It provides coverage for some prescription drugs. It is offered through a private company. Sometimes it is called a PDP. Medicare supplement plan This is an insurance policy. It is offered through private companies. It helps pay for some benefits not covered by Medicare Part A and Medicare Part B. New plans of this type do not cover prescription drugs. It is also known as Medigap coverage. Medication This is a drug a person takes. It can be a prescription drug or an over-the-counter drug. Medigap Also known as Medicare supplement plan. This is an insurance policy. It is offered through private companies. It helps pay for some benefits not covered by Medicare Part A and Medicare Part B. New plans of this type do not cover prescription drugs. It is also known as Medigap coverage. Member This is a department in a health plan company. It helps people understand how their health plan works. It can:
People usually find the phone number for Member Services on their ID card. Member Services This is a department in a health plan company. It helps people understand how their health plan works. It can:
People usually find the phone number for Member Services on their Aetna ID card. Mental disorder This is a problem with brain function. It affects the way people see themselves and the world they live in. It may also affect how they act. Examples include depression, post-traumatic stress and schizophrenia. These types of conditions are not always easy to recognize. They do not show up on blood tests or X-rays. Metastatic (metastasize) This is a word that describes cancer. It means that the cancer has spread. Methodology This is a method or process that is followed. Mg This stands for milligram. It is a very small amount used to measure drugs. Microalbuminuria This is a condition in which high levels of protein are found in the urine. This could signal a kidney problem. Minimum benefit Disability plans provide a source of income for people who cannot work because of illness or injury. Income from other sources may reduce the amount of payment made under the plan. The minimum benefit is the least amount of money a person can get from the plan. See "Other income benefits." Modified adjusted gross income (MAGI) The figure used to determine eligibility for lower costs in the health insurance marketplace, Medicaid and the Children's Health Insurance Program (CHIP). Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest or foreign income you have. Monthly benefit This is for employees who are disabled and covered under a long-term disability plan. It is the amount they can get each month. They get this only while they are not able to work for a period of time. Nasal congestion This means the same as stuffy nose. National Advantage TM program* This is an Aetna program. It offers contract rates for some claims. These claims would otherwise be paid at the cost the doctor billed. It applies to:
*Aetna does not credential, monitor or oversee those providers who participate through third-party contracts. Since several factors determine whether a discount will be given, Aetna is unable to guarantee any level of discount under this program. National Committee for Quality Assurance (NCQA) This is an independent, nonprofit group. It is also known as the NCQA. The NCQA has an official recognition process. It measures how well a health plan:
National Medical Excellence Program® This is an Aetna program. It helps members get covered treatment for:
The services must be done by network facilities. They must have experience in these areas. Nausea This is a feeling of sickness in the stomach. NCQA Also known as National Committee for Quality Assurance. This is an independent, nonprofit group. The NCQA has an official recognition process. It measures how well a health plan:
Necessary Health plans usually pay only for care that is necessary. They decide this by using medical standards or research that states what care is most effective. Care can mean health services or supplies. This also is called medically necessary, medically necessary services or medical necessity. Network A network is a group of health care providers. It includes doctors, dentists and hospitals. The health care providers in the network sign a contract with a health plan to provide services. Usually, the network provides services at a special rate. With some health plans, people get more coverage when they get care in the network. Noncancerous This refers to something that has no signs of cancer. Noncontributory This is the cost of a group insurance plan that is paid by an employer. It can be part of the cost or can be the entire cost. Non-occupational disease This describes a disease not caused by a job or in any act related to a job. Non-occupational injury This is an injury not caused by a job or an act related to a job. Nonparticipating provider This is a health care provider who does not have a contract with a health plan. People might pay more when they visit this kind of doctor, hospital or other health care professional. This may also be referred to as out of network or nonpreferred. Nonprescription This means a person can buy a drug without a doctor's prescription. Obamacare Also known as the Affordable Care Act. It's a U.S. law that changed health care and the health insurance system. Occupational injury or disease This is an injury or disease caused by doing a job. In most states, this is covered by workers' compensation. Occupational therapy People can lose some skills because of an accident or illness. These skills include walking, eating, drinking, dressing and bathing. This treatment helps restore the skills. Open access Some health plans let members see a participating provider without a referral. In other words, they give open access. Also called direct access. Open enrollment People make choices about their health plan coverage during this period. Their choices are for coverage in the next year. Open formulary Some prescription benefits plans cover all eligible prescription drugs. This means they have an open formulary. In these plans, people might have lower copays for drugs on the preferred drug list. They might have higher copays for drugs that are not on this list. Optimum This means most favorable or best. Oral This means by mouth. Oral and maxillofacial surgeon This dental surgeon treats in and around the inside of the mouth and jaws. Original Medicare plan Also known as Medicare Part A: This is part of the original Medicare plan. It is managed by the federal government. It covers some, but not all, expenses for:
The plan has limits. People also must pay deductibles, copays and other costs. OR Medicare Part B: This is part of the original Medicare plan managed by the federal government. People sign up for this plan. They usually pay a monthly premium for the plan. It covers:
It also pays some costs for some:
Orthodontist This is a type of dental specialist. This specialist finds, prevents and corrects problems in how teeth are positioned in the jaws. Other income benefits Disability plans provide a source of income for people who cannot work because of illness or injury. These are called income benefits. Income from other sources may reduce payments made under the plan. These are called other income benefits. They are also called offsets or reductions. Social Security Disability and workers' compensation are two examples. See "Minimum benefit" and "Social Security Disability." Out of network If you choose a doctor or other health care provider who is out of network, your Aetna health plan may pay some of that doctor's bill. But it will pay less than if you get care from a doctor in our network. You will pay more money if you decide to use a doctor that is not in our network. Check your plan documents for more details: Your health plan documents will tell you how we pay for out-of-network care. Or call Member Services at the phone number listed on your Aetna ID card. Out-of-pocket costs These are medical costs that a member must pay. Copays and deductibles are examples. Out-of-pocket maximum This is a limit on the costs a health plan member must pay for covered services. The limit can be yearly or a dollar amount. Outpatient care This is care a person gets in a clinic, emergency room, hospital or surgery center. The person goes home after the procedure. There is no overnight stay. Outpatient procedure Some procedures can be done in a hospital, surgery center or doctor's office. The person goes home after the procedure. There is no overnight stay. This is also called ambulatory surgery. Over-the-counter drugs These are drugs that can be bought without a prescription. They are not covered under most prescription benefits plans. Palliative care This is care given for immediate pain relief. It is not a final treatment for a condition. Partial day treatment This program provides treatment for mental health or substance abuse issues. It is offered during the day or at night. No overnight stay is needed. Partial disability This is when a person has an illness or injury. It stops the person from doing one or more job tasks. This causes the person to earn 80 percent or less of the income earned before becoming disabled. Participating pharmacy This is a pharmacy that has a contract with a health plan. It fills covered prescriptions for plan members. Members might pay less for their prescriptions at this type of pharmacy. Participating provider This is a doctor, hospital or other health care provider. The provider signs a contract with a health plan. The provider is part of the plan's network for covered services. People may pay less when they visit this type of provider. Patient-centered medical home (PCMH) This is a team-based approach to providing health care. A single doctor and care team coordinate all of your care. They work with other specialists and hospitals as needed. A PCMH is used for both simple and complex medical conditions. PCP Also known as primary care physician. This is a doctor who is part of a health plan's network. This doctor is a patient's main contact for care. PCPs give referrals for other care. They coordinate care their patients get from specialists or other care facilities. In some health plans, a person must choose a PCP to coordinate care. PDP Also known as Medicare prescription drug plan or Medicare Part D. This is an optional Medicare plan. It is separate from a Medicare health plan. It provides coverage for some prescription drugs. It is offered through a private company. Pediatric dentist This dentist treats children. Sometimes this dentist is called a pedodontist. Pending claim This is a medical claim that has not yet been approved or denied. Pension This is a retirement fund for employees. It is usually not taxed. An employer pays for or contributes to the fund as part of a benefits package. Periodontal disease This is a dental condition. It affects the gums and bones supporting the teeth. The disease is caused by bacteria that stick to teeth and teeth roots. If not treated, it can destroy the gums and supporting bone around the teeth. It is also called periodontitis. Periodontist This is a type of dentist. This specialist prevents, finds and treats diseases of the gums and bones that support the teeth. Permanent and total disability Sometimes, a person becomes disabled and can never return to work. This benefit provides that person with payment. It replaces some lost income. The payment can be made in one sum or in a series. Permanent partial disability This is an injury or disease that stops people from being able to do all their regular job functions. It causes the person to lose income. This benefit repays some of the income that is lost. Personal health record This is a record of a person's health information. It can include claims and other health history. It is stored online and viewed on a computer. A health plan can add to it. It might add medical claims received and doctor visit information. People can also add their own information to it. They might add information on family health or eating habits. Pharmacy A pharmacy is a drug store. Pharmacy and therapeutics committee This is a group of health care professionals. Doctors, pharmacists and others are on it. The group advises a health plan company on safe and effective drug use. It also helps the plan create a formulary. Pharmacy copay This is a person's share for covered prescription drugs. It is paid to a participating pharmacy. It is a set dollar amount. Physical assistant (PA) This is a person licensed to practice medicine as part of a team with doctors. PAs conduct physicals, prescribe medicine, diagnose and treat illnesses, and may assist in surgery. Physical reaction This describes how the body reacts to something. Physical therapy This is care given to help improve part of the body. It helps ease pain and promote healing. It can also help prevent disability. It is used to limit the effects of disease. It is also used after illness, injury or surgery. Physician This is a medical doctor.
Physician services The ordinary and usual professional services rendered by a physician during a professional visit for treatment of an illness or injury. Placebo This is a substance that has no medicine it. It is also called a sugar pill. It can be given to help people expect to feel better. It is usually used during tests to find out how potential new drugs and treatments will work.
Plan documents A plan sponsor gets important papers from a health plan. These are plan documents. They describe the details of coverage. They include the:
Plan exclusions and limitations These are legal conditions. They apply to health plans. They list specifically what is and what is not covered by the plan. Plan maximum This is a limit on the dollar amount of benefits a health plan will play. Plan sponsor This is a group that sets up and manages a health plan or group insurance plan. It can be an employer. It can also be a labor union, government agency or nonprofit group. Platinum health plan See "Health plan categories." Point of service (POS) This is a type of health plan. It lets members see participating providers. They can also see nonparticipating providers. In many POS plans, members who use referrals and see a primary care physician (PCP) get more coverage. They may pay less for care. Members can get care from a provider who is not a PCP. They might pay more for care. Policy Also known as a contract. This is a legal agreement. It is between a customer (an individual or group) and an insurance plan. It lists all details of the plan's coverage. Policy holder This is a person who has a contract with an insurance company. Portability This is a legal right of an insured person. The person gets to keep group insurance as an individual policy. People don't have to prove they are in good health to keep the policy. POS Also known as point of service. This is a type of health plan. It lets members see participating providers. They can also see nonparticipating providers. In many POS plans, members who use referrals and see a Primary care physician (PCP) get more coverage. They may pay less for care. Members can get care from a provider who is not a PCP. They might pay more for care. PPO Also known as preferred provider organization. This is a type of health benefits plan. Members can choose any doctor. They do not have to name a primary care physician. No referrals are needed. Members who go to network providers usually get more coverage. They may pay less for services. Practice guidelines These are for doctors. They describe the best possible methods to diagnose and treat illness or injury. They are based on medical research. Some call them:
Preauthorization or precertification* This is an important process. It is approval a person gets for care before receiving the care. This helps people know if the care is covered by a health plan. People should check with their plan to see what kind of service needs this approval. This can also be called:
*In Texas, this approval is known as pre-service utilization review and is not verification as defined by Texas law. Pre-disability earnings This is how much money a person earned before a disability. It can be a weekly or monthly rate. Pre-existing condition This is a health condition. It was diagnosed or treated before the date a health plan's coverage began. Preferred care provider Also known as a participating provider. This is a doctor, hospital or other health care provider. The provider signs a contract with a health plan. The provider is part of the plan's network for covered services. People may pay less when they visit this type of provider. Preferred drug list Also known as formulary. This is a list of prescription drugs the health plan covers. It can include drugs that are brand name and generic. Drugs on this list may cost less than drugs not on the list. How much a plan covers may vary from drug to drug. An open formulary provides a greater choice of covered drugs. It is also called a preferred drug list. Preferred provider organization (PPO) This is a type of health benefits plan. Members can choose any doctor. They do not have to name a primary care physician. No referrals are needed. Members who go to network providers usually get more coverage. They may pay less for services. Premium This is the amount paid to a health plan company for coverage. A person can pay it directly. Sometimes a person has a health plan with an employer. Then this cost might be shared between the person and the employer. Premium waiver This is a phrase in a contract. It means an insurer can keep up life insurance coverage for a disabled employee. The employee does not pay for the coverage. Prescription A doctor's order for a drug is a prescription. It is usually written. If it is a verbal order, it must be put in writing by the pharmacy. Prescription drug This is a type of medicine. It must be sold only with a doctor's prescription. It is different than an over-the-counter drug, which can be bought without a prescription. Prescription drug plan (PDP) This is any benefits plan or insurance plan that helps pay for prescription drugs. Prevailing charge A limit on the amount your health plan will pay. Also called usual, customary and reasonable (UCR), customary and reasonable, or reasonable charge. The limit is based on data Aetna receives. The data is based on what doctors charge for the health care service. We receive the data from Fair Health, an independent organization. Check your plan documents for more details: Your health plan documents will tell you how we pay for out-of-network care. Or call Member Services at the phone number on your Aetna ID card. Preventive care This type of care is often covered in a health plan. It includes programs or services that can help people prevent disease. It may include yearly exams, shots and tests for some diseases. The tests are sometimes called screenings. Primary care physician (PCP) This is a doctor who is part of a health plan's network. This doctor is a patient's main contact for care. PCPs give referrals for other care. They coordinate care their patients get from specialists or other care facilities. In some health plans, a person must choose a PCP to coordinate care. Primary care provider A health care practitioner who sees people that have common medical problems. This person is most often a doctor. However, a primary care provider may be a physician assistant or a nurse practitioner. Prior authorization* This is an important process. It is approval a person gets for care before receiving the care. This helps people know if the care is covered by a health plan. People should check with their plan to see what kind of service needs this approval. This can also be called:
*In Texas, this approval is known as pre-service utilization review and is not verification as defined by Texas law. Prior creditable coverage This term means types of health coverage a person has had. People sometimes need to prove they have had this so they can be fully covered by a new plan. Some examples of acceptable types are:
Private fee-for-service plan This is a type of Medicare Advantage plan. It is offered through a private health plan company. A person pays a premium for medical coverage. Then, the person can go to any doctor or hospital that:
Progressive In health care, this refers to an illness or condition that gets worse over time. Prophylaxis This is a routine health service. A doctor or dentist does this to preserve health and prevent the spread of disease. Prosthetic device This is an artificial body part. It is used to replace a body part that is damaged, missing or not working properly. It can replace teeth, eyes, arms, legs or hands. Prosthodontist This is a type of dentist. This dentist restores or maintains dental health by replacing natural teeth. A person might see this specialist for dentures. Provider This term is used often by health plans. It means a licensed person or place that delivers health care services. Some examples are doctors, dentists, hospitals and more. Provider network Also known as network. A network is a group of health care providers. It includes doctors, dentists and hospitals. The health care providers in the network sign a contract with a health plan to provide services. Usually, the network provides services at a special rate. With some health plans, people get more coverage when they get care in the network. Provider Search This is Aetna's online directory. It lists doctors and health care professionals in the network. Members use it to find care near where they live. The list has doctors, hospitals, dentists, pharmacists and more. Patient Protection and Affordable Care Act (ACA) This is also known as the Affordable Care Act or ACA. It was signed into federal law in March 2010. The goals are to help more people get health care coverage, improve care quality and efficiency, and reduce costs. Learn more about the ACA Radiation therapy This is a treatment used to fight cancer. High-energy rays damage cancer cells so they stop growing. Reasonable charge A limit on the amount your health plan will pay. Also called usual, customary and reasonable (UCR), customary and reasonable, or prevailing charge. The limit is based on data Aetna receives. The data is based on what doctors charge for the health care service. We receive the data from Fair Health, an independent organization. Check your plan documents for more details: Your health plan documents will tell you how we pay for out-of-network care. Or call Member Services at the phone number listed on your Aetna ID card. Reasonable occupation or job This is a paid occupation or job a disabled person can get through training or skill. Recognized charge A limit on the amount your health plan will pay. Also called the allowed amount. If you choose to go out of network, your provider may not accept this amount as payment in full and may bill you for the rest. This is in addition to your plan's required copays and deductibles. Check your plan documents for more details. They will tell you how we pay for out-of-network care and how we calculate the recognized charge. Or call Member Services at the phone number listed on your Aetna ID card. Reconstructive surgery Surgery performed to restore function and normal appearance and correct deformities created by birth defects, trauma or medical conditions, including cancer. Recurrent disability This means a person gets disability benefits more than once for the same reason. There is a period in between when they are back at work. There is a limit to how long this time period can be. Referral This is a form your doctor gives you so you can get care from a specialist or health care facility. It may be written or sent by computer. Rehabilitation program This is a program that helps people improve their health so they can return to work. Physical, mental and career training is used. Rehabilitation services Rehabilitation services help you restore or develop skills and functioning for daily living. They include short-term services prescribed by your physician, such as physical, occupational or speech therapy. Reimbursement This is money you get back from your health plan for covered costs you paid to your doctor. Related absences This is when a worker is out of work two different times or more. The worker is out for the same health problem each time. Reline This is when a dentist resurfaces part of a denture to make it fit better. Renewal This is when an insurance policy continues, but with changed terms, like new rates. Respite care This is care that gives families a short break from the duties of constant care. Retiree This is an employee who has retired from working. To retire, an employee must meet the employer's rules for minimum age and years of service. Retiree reimbursement account (RRA) This is a type of account people can use after they have retired. It can help pay for health plan premiums and medical costs. The employer puts money into the account. Balances roll over year to year, per employer rules. Retirement rule This rule sets the benefit amounts that retired workers can get. Return-to-work (RTW) incentive This lets workers who were disabled return to work part time. They can return if their disability benefits and pay are less than what they earned before they were disabled. Rider This is a policy that is separate from the main policy. It has changes in it that affect the main policy. Risk This is the chance or likelihood of loss. Rollover feature This lets a person carry forward or "roll over" any balance in a health fund. The amount can be used to pay for health care costs in future years. RRA Also known as retiree reimbursement account. This is a type of account people can use after they have retired. It can help pay for health plan premiums and medical costs. The employer puts money into the account. Balances roll over year to year, per employer rules. RTW Also known as return-to-work incentive. This lets workers who were disabled return to work part time. They can return if their disability benefits and pay are less than what they earned before they were disabled. Rx This is a common symbol. It means prescription or pharmacy. Vocational evaluation This helps rate how willing and able a person is to return to work. It also shows how well the person will relate to managers and coworkers. A formal one uses standardized tests and direct observation of the worker doing job tasks. This is usually done at a rehabilitation center. An informal one is an interview usually done by a private job counselor. Voluntary plans These are group benefits offered by the employer. They are paid for completely by the employees. Walk-in clinic This is a health care center. You find it in many supermarkets and pharmacies. A clinic treats minor illnesses and injuries. It also offers health screenings and vaccines. The clinic is often open evenings, weekends and holidays. When you can't see your regular doctor, a walk-in clinic can be a good option. W-2 This form is used to report a person's income to the Internal Revenue Service (IRS). Weekly benefit This is the amount of money an employee can get while out of work on disability. It is the amount paid each week. It is subject to the terms of the insurance policy or plan document for the group short-term disability plan. Fully insured companies use the policy. Self-insured companies use the plan document. Well baby care This is the routine care a child needs through the age of 8. It includes checkups, tests and shots. Well child care Also known as well baby care. This is the routine care a child needs through the age of 8. It includes checkups, tests and shots. Well woman care This is the regular care a woman needs. It includes checkups with the Obstetrician/Gynecologist and regular pregnancy care. Wellness programs These programs help people stay healthy. They may include ways to prevent disease, stay fit and care for one's own health. They show people healthier ways to live. Work adjustment This can help workers improve their skills and attitude on the job. Workers may get formal counseling. Or they may be supervised while doing job tasks in a rehabilitation center. This is often used with workers who have not worked for a long time. It is also used with people who have learning or psychiatric problems. Work hardening Workers enter this program after physical therapy but before they return to work. They stay in it for two or four weeks. It helps improve physical abilities by using actual work tasks. Workers can start this program only if they are motivated and ready to return to work. A job must also be available for them. The job must be open so they do not lose the skills and abilities gained during this program. Workers' compensation This covers workers when they are hurt on the job. These workers receive pay for medical costs and disability pay under this law. It is available in all 50 states, American Samoa, Guam, Puerto Rico and the U.S. Virgin Islands. UCR Also known as usual, customary and reasonable. This is a limit on the amount your health plan will pay. Also called customary and reasonable, reasonable or prevailing charge. The limit is based on data Aetna receives. The data is based on what doctors charge for the health care service. We receive the data from Fair Health, an independent organization. Check your plan documents for more details: Your health plan documents will tell you how we pay for out-of-network care. Or call Member Services at the phone number listed on your Aetna ID card. Uncovered services These are also called exclusions. They are specific conditions or services that are not covered under a health plan. They are listed in the plan documents. Check to see what is not covered before enrolling in a plan. Ask the plan or your employer for a copy of the plan documents. Underwriting This process helps assess the costs of insuring potential members. It is used to decide who is eligible for coverage. Medical questions may be asked. A health exam may be required. Rate level and premiums are based on results. Urgent care centers These centers can treat urgent, but non-life-threatening medical issues. A few examples are sprains, fractures and minor burns. Urgent care clinics are a convenient option to the emergency room. They're staffed with nurses and doctors. You wait less. You don't need an appointment. Many are open seven days a week. And you usually pay less. If you have a medical issue that threatens your life, always visit your local emergency room first. Usual, customary and reasonable (UCR) A limit on the amount your health plan will pay. Also called customary and reasonable, reasonable or prevailing charge. The limit is based on data Aetna receives. The data is based on what doctors charge for the health care service. We receive the data from Fair Health, an independent organization. Check your plan documents for more details. Your health plan documents will tell you how we pay for out-of-network care. Or call Member Services at the phone number listed on your Aetna ID card. Telemedicine This allows doctors to treat patients without an office visit. They use video, telephones or e-mail to talk. This can help improve care. And patients in remote places can get help from doctors and specialists who are far away. Temporary partial disability This is an employee benefit. It offers limited pay to employees who are back to work, but cannot perform their regular jobs. Only workers who were injured on the job can receive this pay. Temporary total disability This is an employee benefit. It offers limited pay to employees who cannot work at all. Only workers who were injured on the job can receive this pay. Temporomandibular joint (TMJ) This is a joint that connects the jaw to the skull. There are two of them. One sits in front of each ear. Temporomandibular joint disorder (TMD) This includes pain and other symptoms affecting the head, jaw and face. It is caused when the jaw joints and muscles controlling them don't work together correctly. Term insurance This is a type of life insurance. It is in effect only during the period, or term, for which premiums are paid. It does not build up cash value. Tertiary care This is specialized medical care. It involves complex procedures. People usually need this care for a long time. Specialists in state-of-the-art medical centers give the care. TMD Also known as a temporomandibular joint disorder. This includes pain and other symptoms affecting the head, jaw and face. It is caused when the jaw joints and muscles controlling them don't work together correctly. TMJ Also known as temporomandibular joint. This is a joint that connects the jaw to the skull. There are two of them. One sits in front of each ear. Total disability (any occupation) This means a person cannot perform any occupation. This happens because of illness or injury. It is determined by things such as work experience, job history or the job market. Total disability (own occupation) This means you are unable to perform your own occupation for any employer. It may occur because of illness or injury. Traditional plan Also known as an indemnity plan. This is a type of health plan. Members can get care from any licensed doctor or hospital. They get the same level of benefits no matter who they see. There is no network. The plan pays a percentage of each covered health care service. These plans often have deductibles, coinsurance and certain benefit maximums. Transferable skills analysis This test helps people find a new job when they can no longer perform their current job. This may happen because of illness or injury. The employer looks at skills the worker has. Skills from past jobs, education or other activities are reviewed. Then these skills are matched with a position the worker is likely to be able to handle. Salary continuation This is for when employees are disabled for a short time. The employer pays part or all of the employees' salary. Schedule of benefits and exclusions This list states what a policy does and does not cover. Second opinion This is an opinion you get from a second doctor. You get this after you receive an opinion from the first doctor you went to see. It gives you a chance to compare the two opinions. Then you can decide how you want to treat your problem. Self-funded plan Also known as a self-insured plan. This is a type of plan in which the employer takes on most, or all, of the costs of benefit claims. The benefit company manages the payments. But the employer is the one who pays the claims. These plans are often more flexible for the employer. That is because the employer is often not subject to state law requirements. Self-insured employer This is an employer who pays benefit claims for employees. The employer takes on most, or all, of the risk of the costs of benefit claims. The benefit company manages those payments. Self-insured plan This is also called a self-funded plan. This is a type of plan in which the employer takes on most, or all, of the costs of benefit claims. The benefit company manages the payments. But the employer is the one who pays the claims. These plans are often more flexible for the employer. That is because the employer is often not subject to state law requirements. SEP Also known as a special election period. This is for people with a Medicare plan. It is a time when they can change their benefits because something in their life changes. Examples are moving out of a plan service area, or being able to get Medicaid. If nothing in their life changed, they must wait for an enrollment period. Service area This is an area served by a health plan. It is where the plan is licensed to accept members. It is also where a network of doctors exists to give health care services. Short-term disability (STD) This pays part of a worker's pay while out of work. The person must be out of work for a short time with an illness or injury that is not related to work. Short-term health insurance This is a type of health care plan that fills gaps in a regular plan. It gives you benefits when you are between jobs, after a move or when you are out of the country. It usually lasts for one year or less. And it usually cannot be renewed. Sickness This is a condition for which you would need medical care. Silver health plan See “Health plan categories.” Skilled nursing facility (SNF) This is a place that gives nursing care to people who do not need to be in a hospital. It is licensed. It gives rehabilitation and other care, too. It does not include nursing homes or care for those who need help with daily living. Small business health insurance This is health insurance for companies that have 2 to 50 employees. These plans help employers save on their taxes. And they help employees save on their premiums. SMI See "Supplemental medical insurance." This is also called Medicare Part B. This insurance covers basic medical needs. It is paid by both the insured person and the government. SNF Also known as a skilled nursing facility. This is a place that gives nursing care to people who do not need to be in a hospital. It is licensed. It gives rehabilitation and other care, too. It does not include nursing homes or care for those who need help with daily living. SNP Also known as a special needs plan. This is a Medicare Advantage HMO or PPO plan. It is for smaller groups of people who get Medicare. There are three types of these plans. The first type is for those who receive both Medicare and state Medicaid. The second type is for those who live in a longterm care home. The third type is for those with a condition that is disabling. Social Security retirement benefits This is a retirement program run by the government. It is paid for through federal income tax money. It gives Americans a check each month based on the years they have worked and the money they have earned during their life. A person can start collecting benefits at age 62. The more money a person has earned, the higher the Social Security check amount may be. If they have earned less, their check amount may be lower. Special benefit networks These are groups of doctors, specialists or health centers. They give care for special services. For example, services could be for mental health and drug abuse. Special election period (SEP) This is for people with a Medicare plan. It is a time when they can change their benefits because something in their life changes. Examples are moving out of a plan service area, or being able to get Medicaid. If nothing in their life changed, they must wait for an enrollment period. Special needs plan (SNP) This is a Medicare Advantage HMO or PPO plan. It is for smaller groups of people who get Medicare. There are three types of these plans. The first type is for those who receive both Medicare and state Medicaid. The second type is for those who live in a long-term care home. The third type is for those with a disabling condition. Specialist This is a doctor who is trained to give care in a specific medical area. The doctor's focus could be on a disease, part of the body or age group. Speech-language therapy This is treatment to improve a person's speech or language skills. The problem could have started from birth. But it could also have been from a disease, an earlier medical treatment or a time when the person got hurt. Staff model This is a type of HMO plan. Doctors are employees of the HMO. This is different from an independent practice association (IPA) HMO. In an IPA-model HMO, the doctors are not employees of the HMO. State insurance department This is an agency that makes state insurance laws. It also makes sure insurance companies follow the laws in the state. State-mandated benefits These are benefits a state requires in a policy. If the benefit is not in the policy, it cannot be sold in the state. STD Also known as short-term disability. This pays part of a worker's pay while out of work. The person must be out of work for a short time with an illness or injury that is not related to work. Step therapy This is a way that a health plan controls drug costs. It means a person must try certain drugs before the plan will pay for a particular brand-name drug. The first drugs are often generic and cost less. Stop-loss coverage This protects employers who take on most of the risk of a health plan. An employer can buy this to avoid having to pay for large health claims. If health care costs go over the amount listed in the contract, the plan will pay the rest. Subscriber This is a person who signs up for a health plan. If it's a family health plan, the subscriber add people to it as dependents. Those people must be eligible to join. Some health plans also use the word enrollee for this term. Successive disabilities This is when a person is disabled two or more times. Each time is due to the same condition. Or each time can happen because of a related condition. Each episode is separated by a time period that is stated in the contract. Summary of Benefits and Coverage (SBC) This document tells you what a health plan covers and what your share of the costs will be. For example, it lists your deductible, copay and out-ofpocket limits. All plans must use the same format for the SBC, so you can easily compare plans. You can check this document when shopping for or enrolling in a plan. Or you can ask for a copy from your insurance company or group health plan at any time. Supplemental life insurance This is extra life insurance. An employee can buy this to get more than the basic amount given by the employer. Supplemental medical insurance (SMI) This is also called Medicare Part B. This insurance covers basic medical needs. It is paid by both the insured person and the government. Survivor benefit This has to do with a disability plan. It pays money to a living person if the person who holds the policy dies. The living person's name is on the policy. Which of the following statements most correctly describes the accidental death benefit rider on a life insurance policy?Which of the following statements regarding the accidental death benefit (ADB) rider to a life insurance policy is correct ? Benefits are payable under the accidental death benefit rider only if the insured dies as the direct result of an accident.
What is an accidental death benefit rider?The term accidental death benefit refers to a payment due to the beneficiary of an accidental death insurance policy, which is often a clause or rider connected to a life insurance policy. The accidental death benefit is usually paid in addition to the standard benefit payable if the insured died of natural causes.
What is ADB rider in insurance?The Accelerated Death Benefit (ADB) is a provision in most life insurance policies that allows a person to receive a portion of their life insurance money early — to use while they are still living. ADB is a standard in the industry and offered by most life insurance carriers.
What is considered accidental death for insurance?In the United States, accidental death is defined as death caused by an unexpected event or happening (accident). Any death that is not intended, expected, or anticipated constitutes an accidental death.
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Which of the following statements correctly describes the accidental death benefit ADB rider on a life insurance policy?
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