A

Accelerated Death Benefit (ADB)

This can help people who have a fatal illness. The member or spouse can get specific life insurance benefits as an early payment.

 

Accidental Death and Dismemberment (ADD)

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.

 

Accident

The sudden action of an external force causing impairment of physical integrity. 

 

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 staff

This term refers to a person who works a normal workweek for an employer. Staff must work at least the number of hours shown in a plan's Schedule of Insurance.

 

ADA

This term refers to the Americans with Disabilities Act which is a US law that protects the rights of people with disabilities. It helps prevent them from being treated unfairly on the job.

 

ADB

This term refers to the accelerated death benefit.

 

ADEA

This term refers to the Age Discrimination Employment Act which is a U.S. law that protects people against unfair treatment in the workplace due to age.

 

ADD

This term refers to Accidental Death and Dismemberment.

 

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 $50K before you become disabled at age 40. With no adjustment to your income, inflation would greatly reduce your buying power by the time you reach age 60.

 

ADPL

This term refers to accidental death and personal loss coverage.

 

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 also called a living will.

 

Administering Office

The office that has the responsibility for the day-to-day operation of the plan (for example, enrolment, collection of contributions from active and former staff members, premium accounting) at a given duty station. 

 

Aetna Health Fund

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 the First Dollar Plan. 

 

Aexcel

Aetna uses this mark for some specialist doctors. These doctors have met certain performance levels for their medical care and cost. 

 

After Service Life Insurance (ASLI)

ASLI is a continuation of your GLI plan. If you would like to maintain your GLI after your transition from active staff to retiree, you will automatically be enrolled in ASLI without paying any additional premiums after your retirement. If you would like to know more about related age-scale reductions or other details of this plan, please visit the Life Insurance Page of this website (insert link).

 

After-Service Participant

Retirees, participating survivors and recipients of a periodic disability benefit from the United Nations Joint Staff Pension Fund and/or appendix D to the Staff Rules (rules governing compensation in the event of death, injury or illness attributable to the performance of official duties on behalf of the United Nations). 

 

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 co-pays and deductibles.

 

Amalgam

This is a type of filling made up of several different metals. It is silver in color and is mainly used on back teeth.

 

Ancillary Services

These are services provided to support your health care. Some examples include X-rays or lab tests.

 

Annual Enrollment Campaign

Period during the year when a subscriber can enroll or terminate coverage for eligible family members after the original 31-day period following a qualifying event; the annual enrolment campaign takes place during a set period every year with the effective date of coverage being 1 July. 

 

AEP

This term refers to the annual coordinated election period which is a time when you can make changes to your Medicare plan. It runs from November 15 through December 31 each year.

 

Appeals Process

This process allows you to ask for a review of claims that have been denied by your health plan.

 

B

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 are in-network will not do this.

 

Balance Billing for Medicare

Doctors or hospitals that do not charge the fees 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.

 

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 or Medicaid. 

 

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. For more information, please see the Lifetime maximum term description

 

Benefit period

This is a maximum length of time during which benefits will be paid.

.

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.

 

Brand-name drug

This is a medicine that is protected by patent. It can only be given to you with a prescription.

 

C

Calculus (or Tartar)

This is when plaque left untreated on your teeth begins to harden. It then becomes known as calculus or tartar.

 

Capitation

This is a fixed amount of money doctors and hospitals get from health plans to serve plan participants. This amount is independent from the quantity of patients they see.

 

Career counseling

This is a toll to help people further their career. Job skills, abilities and work habits are reviewed. Results are compared and matched to other jobs. The objective is to provide exposure to future opportunities.

 

Caries

This is a dental term that refers to cavities or tooth decay.

 

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.

 

Certificate of Coverage

This details the benefits provided by your health plan. It lists benefits that are covered and not covered.

 

Certification of a period of disability

This is a tool to determine if an employee is truly disabled. The terms of the policy are used to decide this.

 

CFP

This term refers to Certified Financial Planner/s who is someone who helps people plan how to save and use their money. The Planner has been qualified by the Certified Financial Planner Board of Standards, Inc. This means the person passed certain tests to get the CFP title. All CFPs have to take certain classes every two years to keep this title.

 

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 provides this care.

 

Claim

This is a request to be paid by a health plan for provided health services. An example would be the claim your doctor sends to your health plan provider for an in-office visit. It is also a request for payment under a disability or life insurance plan.

 

Closed Formulary

This is a type of pharmacy benefits plan. It only covers prescription drugs on the plans list. The list is called a formulary. Drugs not on this list need to be approved by the plan before they can be covered.

 

CMS

This term refers to Centers for Medicare/Medicaid Services which is a USA federal agency that runs the Medicare program. It also works with states to run the Medicaid program.

 

COB

This term refers to Coordination of Benefits which are rules used to decide which plan pays first for people who have more than one plan. It helps coordinate coverage and allows claim information to be shared by the plans. This way, the plans can avoid duplicate payments.

 

COBRA

This term refers to the Consolidated Omnibus Budget Reconciliation Act of 1986. That law allows you to continue your health plan coverage for a limited time. It is often used after people lose their job or become divorced. If you choose this option, you will pay the entire cost of coverage. 

 

Coinsurance

A subscriber’s share of the cost of a covered health-care service or expense that is usually calculated as a percentage of the allowed amount for a service. For example, if the plan covers 80 per cent of the reasonable and customary cost of a service, the co-insurance is 20 per cent or the share that the subscriber is responsible for. 

 

COLA

This term refers to Cost of Living Adjustment which 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 applies when two people live together for a certain amount of time. They can be considered married because of the time spent together. Some states agree and recognize them as married.

 

Complication of Pregnancy

This is a health problem that can occur during pregnancy. It is something that would not happen in a normal pregnancy and 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 birth condition.

 

Consumer-directed health plan

This type of 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. 

 

Consumerism

This is a term for a new movement in health care. Its goal is to get plan participants more involved with their own health 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 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 that refers to a customer (an individual or group) who buys an insurance plan from an insurer.

 

Contributory

This term refers to the nature of a group health plan. It means costs are shared between an employer and its staff.

 

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.

 

Coordination of benefits

The settlement of reimbursable medical expenses where more than one medical insurance scheme covers a subscriber and/or his or her eligible family members (the instances when a health insurance plan of the United Nations health insurance programme is considered the secondary plan are described in paras. 23 and 43 of the main text). 

 

Copay

This is the out-of-pocket 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

Cost is an amount paid or required in payment for a purchase.

 

Coverage gap

This is also called the "donut hole." It is the part of the Medicare plan where plan participants pay for prescription drugs whithout subsidies by the plan. 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

These are services or supplies your health plan covers. They are eligible to be paid by your plan.

 

Credentialing

This refers to a process used to ensure that doctors and hospitals meet certain standards. It is also used for other health professionals and facilities.

 

Creditable Coverage Medicare

This applies to people who are eligible for Medicare. It refers to 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 without being charged higher fees if you switch to Medicare later.

 

Crown Lengthening

This is a way to expose more of a tooth. The dentist removes gum tissue and bone. Dentists do this when patients do not have enough tooth above their gum line to support a crown or filling.

 

Custodial Care

This refers to care that helps people with their daily life activities. The person providing the care does not have to be trained in medicine. This care may help people with walking, bathing, dressing and eating.

 

CnR

This term means Customary and Reasonable. It refers to 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 capturing what doctors' charge for the health care service. Your health plan documents will tell you how we pay for out-of-network care.

 

D

DCI

This refers to the Date Claim Incurred (DCI) which is used for disability plans to capture the date a person becomes disabled. It is also called Date of Disability.

 

DCR

This refers to the Date Claim Received which is the date on which the insurance company reviews submitted claims.

 

DLW

This refers to the Date last worked which is the last day a person worked before they became 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.

 

Day Treatment Center

This is a place where people can get mental health care. The person does not stay overnight. 

 

Death Benefit (also known as Face amount)

This term applies to life insurance. It is the money that an insurance company pays when an insured member dies.

 

Debridement (dental)

This term refers to a process in which a dentist removes large amounts of plaque and tartar. This makes it easier to examine your teeth. It is usually done when teeth havent been cleaned in a long time and there is a lot of buildup.

 

Debridement (medical)

This refers to the process of a nurse or doctor cleansing a wound.

 

Deductible

This term refers to the amount you pay for covered services before your health plan begins to pay.

 

Deductible (Medicare)

This refers to the amount plan participants must pay for health care before the Medicare Plan coverage begins to pay. The amount is subjected to changes each year.

 

Defined Contribution Plans 

There are many different types of these plans. If covered under these plans, employers give each employee a fixed amount of money that can be used 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.

 

Dental services

Services performed by a dental practitioner or a dentist who is licensed to practise dentistry in the country in which he or she practises the profession. 

 

Dependant

This is a person who is covered by another person's plan. It can be a recognized spouse or one or more dependent children.

 

Dependent Care Reumbursement Account

Plan participants 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 and it cannot be rolled over to the next year. Also, the money cannot be taken from one job assignment to another.

 

Diagnostic tests

These are tests that a health care professional orders. The tests help to determine if a person has a condition or a disease. X-rays and ultrasounds are examples of these tests.

 

Diagnosis

The identification by a licensed physician of an illness or nature of a disease. 

 

Direct Access (also called 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 and absence management

These are services and products that help employers keep track of general absences and leaves of absences of their employees.

 

Disability Management

This is the money paid to a plan participant in case they are 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 plan participants manage their health and prevent future problems.

 

DocFind

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.

 

Domestic Partners

This means two people who live together but are not married. They are responsible for each others well-being and finances. They may or may not be a same-sex couple.

 

Drug

This term refers to a natural or man-made substance used to treat an illness.

 

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 refers to a situation in which you and your dependents have the same coverage through two or more health plans.

 

DME

This term refers to durable medical equipment which is the equipment a person needs and which is: made for and mainly used to treat a disease or injury reusable and made for long-term use appropriate for home use not for use in altering air quality or temperature not for general exercise or training. Examples are wheelchairs or hospital beds used at home.

 

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 services.

 

E

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 refers to terms determining who can get coverage. The requirements vary. They could include how long a person is employed, job status and more. In addition, Life Insurance requirements could also include health conditions.

 

Eligibility file

A file that is sent electronically to the third-party administrator that contains information on all active or retired staff members and their eligible family members who are covered under the plan; this file is the basis on which the third-party administrator determines who is eligible for coverage under the United Nations health insurance programme. 

 

Eligible family members

A subscriber’s recognized spouse and one or more dependent children, as defined in staff rule 3.6 (a) (iii). The United Nations health insurance programme recognizes only one eligible spouse. A subscriber’s children who meet the criteria for a dependent child under staff rule 3.6 (a) (iii), but for whom the staff member does not receive a dependency allowance owing to local limits on the number of children for whom a dependency allowance is payable, may also be considered as an eligible family member for the purpose of enrolment in the plan. In the case of an after-service subscriber, eligible family members are defined as the spouse and children already enrolled at the time of separation from service and any child born within 300 days of separation. A staff member’s parents, brothers and sisters, whether or not recognized as secondary dependants, are not eligible for the plan. 

 

Eligible former staff member

A former staff member who meets the eligibility criteria for after-service health insurance as set out in section 7 below on after-service health insurance.

 

Elimination period

This is the amount of time a person must be disabled before he or she 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.

 

Emergency medical care

Medical treatments that are undertaken owing to an unplanned, sudden and acute illness or injury and which, for medical reasons, cannot be delayed or postponed. 

 

Enrolled family member

An eligible family member who is enrolled in the United Nations health insurance programme. 

 

EAP

This term refers to the Employee Assistance Program which 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. Employees do not pay for an EAP.

 

ERISA

This term refers to the Employee Retirement Income Security Act of 1974 which is a law that controls employer-based health plans. It also sets rules for pensions and other benefits plans.

 

Endodontist

This term refers to a dental specialist. He or she treats diseases of the tooth's nerves or pulp. Nerves and pulp are in the tooths center and canals. You often hear the canals being called root canals. That is because they are in the tooth's root.

 

Enrollee

This is another term for plan participants. 

 

Enrollment period (Medicare)

This refers to the period during which 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.

 

Ergonomic Evaluation

This evaluation is based on a person's physical work space. The goal is to make sure it is safe and comfortable. Its 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 employee. The idea is to help the employee be physically safe and comfortable. This is important to the employee's health while they perform daily tasks. It could refer to having the right chair, keyboard, desk or a headset if the worker has to be on the telephone a lot.

 

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.

 

Evidence of Insurability (EOI)

This term refers to the process necessary to enroll in the Hartford Life Insurance Plan in case you missed the initial 60-day enrollment period after commencing your assignment. In case you do enroll within 60 days after your initial appointment, you will automatically be enrolled in the UN GLI, however, after this period you will have to apply through the EOI process facilitated directly by the Hartford TPA.

 

Explanation of Benefits (EOB)

A statement that is sent to a subscriber by the third-party administrator that shows medical expenses claimed, reimbursement by the plan and any balances that are the responsibility of the subscriber. It may be sent by mail or email or as a downloadable document from the third-party administrator’s website. 

 

F

Facility-of-payment provision

This can be part of a life insurance policy. It lets insurers pay out some of the benefits 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.

 

FMLA

This term refers to the Family and Medical Leave Act which is a law for employers with 50 or more employees. It applies to workers who need to take time off from work for:

• Birth and care of a newborn child up to 12 months old
• Adoption or foster care of a child
• Care of an immediate family member (spouse, child or parent) with a serious health condition
• Medical leave because of a serious health condition that leaves a worker unable to do his or her job

Employees 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.

 

FEHBP

This term refers to the Federal Employees Health Benefits Program which is a type of health plan. Most federal government workers are covered under it.

 

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.

 

First dollar plan

This can be a health plan without a deductible. It can also be a health plan with a high deductible. This plan pays for some services before the member has to pay money on his or her own. Covered services are paid out of a special fund first. Once the fund is used up, the member must satisfy the deductible before receiving coverage under the plan. Funds for this plan do not roll over from year to year.

 

FSA

This term refers to the Flexible spending account which is is a way by which employees can set aside money to help pay for health care. It is used with a health benefits plan. The employee asks for money to be taken from his or her 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.

 

Formulary

This is a list of prescription drugs covered by the health plan. It can include drugs that are brand name as well as 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.

 

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 term refers to an exam 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 hands. The tests are used show if the employee can resume normal job activities.

 

G

Generig 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.

 

Gingivitis

This is a type of gum disease. It refes to swelling of the gum tissue caused by plaque. Gums may appear red and swollen. They may bleed easily during brushing. It is one of the first stages of periodontal disease.

 

Group Coverage

This is a plan offered by a plan sponsor to a staff group or other group. The plan offers health, dental, life insurance coverage and more. Group plans may also be offered to retirees.

 

Group Life Insurance (GLI)

For the UN in particular, this term refers to the optional Hartford Life Insurance Plan available through the UN Health and Life Insurance Section. For more details about this plan, please visit the Life Insurance Section of this website.

 

GUL

This term refers to Group Univeral Life which is a life insurance product that 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 term applies to life insurance plans. It is the dollar amount a person may qualify for without proof of good health.

 

H

Health Assessment

A health assessment is a form or online 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 best 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 in-network doctors only.

 

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 term refers to a company that provides health insurance plans.

 

HIPPA

This term refers to the Health Insurance Portability and Accountability Act which is a federal law that 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 persons 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

This term refers to the health maintenance organization which is a health plan that arranges health care services for its members. In most HMO plans, participants choose a primary care physician (PCP). The PCP is from the health plans' in-network provider list. The PCP gives routine care and refers members to in-network doctors if special care is needed.

 

HMO (Medicare)

This term refers to the Medicare health maintenance organization which is a type of health plan that 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.

 

Hospital

An institution licensed by the Government to provide medical and surgical treatment and nursing care for sick or injured persons. Such care normally involves overnight stay (or inpatient care), thus requiring such facilities to have inpatient beds and continuous physician and nursing services under the supervision of licensed professionals. These facilities may also provide same-day treatments (outpatient care). 

 

HRA 

This term refers to the Health Reimbursement Arrangement which is a part of a health plan that lets members use a fund to pay health care costs. The employer puts money into a fund that plan participants can use 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

This term refers to the Health Savings Account which is part of a health plan. Plan participants can put money into this account that can be used to pay for covered health care costs.  The account grows interest. Plan participants can take their account with them if switching employers. You must be covered by a high-deductible health plan to qualify for an HSA. 

 

Health Care

This term refers to the maintenance and improvement of physical and mental health, esp. through the provision of medical services.

 

HDHP

This term refers to high-deductible health plans which are plans that have to meet federal rules. This way plan participants can put money into a health savings account or health reimbursement arrangement. The plan deductible is higher than a standard health plan. Premiums are lower.

 

Home health care

This term refers to care services given in a patients home. It is often offered after a hospital stay. Coverage depends on the patients needs and their health plan.

 

Home infusion therapy

This is a type of medical treatment offered in a patients home. The patient is given medication through a vein. Nutrients and fluids may also be given this way.

 

Hospice

This is a type of nursing and supportive care. It is given to patients who are ill and near death. This care can be given 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.

 

I

ID Card

This is the card members get when they join a health plan. It lets doctors and other health care providers know what coverage a patient has. It shows the members assigned plan number and plan contact information. The card should be shown at every health care visit.

 

In-network providers

This term refers to providers that have special arrangements related to the respective health plan. The TPAs negotiated reduced rates with them to help plan participants save money. Your out of pocket costs are lower when you visit in-network providers. There are other benefits to using doctors in network. They wont bill you for the difference between their standard rates and the rate they've agreed to with the TPAs. All you have to pay is your coinsurance or copay, along with any deductible. In-network providers will also handle any precertification your plan requires.

 

Indemnity Plan

This is a type of health plan. Plan participants can get care from any licensed doctor or hospital. They get the same level of benefits no matter who they see. There are no networks. 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 exam is needed to help decide on a disability claim. A doctor examines the person in question. This doctor has not treated the person before.

 

IPA

This term refers to the Independent Practice Association which is a group of doctors or other health care providers. They contract with one or more health plans to provide services. If a plan participant sees a primary doctor in this group, they will be referred to specialist and hospitals in the same group. Plan participants can go outside the group if their medical needs cannot be handled by this group.

 

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.

 

IRA

This term refers to the Individual Retirement Account which 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 plan participants pays a set amount until the plan payments hit a certain total. Once this limit is reached, the terms change. Plan participants may pay more as the plan moves to the coverage gap phase.

 

IEP

This term refers to the initial enrollment period which lasts 7 months. It happens around 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 can be put into the body 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.

 

Inpatient

This is a person who has to stay in the hospital for care for at least one night.

 

Inpatient Care

Services provided to a person who has been admitted to a hospital and will stay one or more nights. 

 

IHD

This term refers to the Integrated Health and Disability program which 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.

 

InteliHealth

This is a health website run in part by Aetna. The full name is Aetna InteliHealth®.

 

 

J

Jaundice

This refers to the yellowing of the skin or the part of the eyes that should be white. Please seek treatment bya health care provider immediately once this occurs as it could signal a severe liver problem. 

 

Job Analysis

This analysis takes place to determine the skills needed for a job. The person conducting it interviews the employee and supervisor. He or she can also observe how the job is done. It is needed to help people return to work after a long illness or injury. 

 

Job-seeking skills training

This is a way to help people get back into the job market. Counselors show them how to look for jobs and prepare for interviews. Counselors use video to tape people practicing their skills. Trainees can then see what they can improve on.

 

K

 

L

Labor Market Survey

This is a review of the kinds of jobs in a geographic area. It is used to help people return to work. The data comes from the U.S. Department of Labor and from interviews with local employers. The goal is to find out if a certain job or skill can be used in that job market.

 

Lapse (also called lapse in coverage)

Anyone who buys an insurance plan pays a premiums. Plan Participants pay this amount monthly. If you miss a payment, the insurance company can cancel your coverage. It means you have let your insurance coverage lapse/end.

 

LASIK

This terms refers to laser-assisted in situ keratomileusis which is a procedure to correct your vision using lasers.

 

Late Entrant (also known as late enrollee)

There are certain times of the year when employees can choose or change plans. The main period to do so is during annual enrollment. New staff can enroll within 31 days after commencement of their appointment or during the annual enrollment campaign. The same applies to occurences such as getting married or having a baby.

Late entrants are:

• New staff who do not sign up within 31 days of being hired. 
• Staff who do not choose or change coverage within 31 days of getting married or having a baby. 

 

Lateral

This is a medical term used to describe a position within the body. It means the left or right side of the body or body part.

 

Length of disability

This term refers to the period of a person being 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.

 

Lesion

This is a wound or sore. It is an infected patch of skin.

 

Level amount schedule

This is a benefits schedule. It lists how much of a benefit each employee gets. All employees on it get the same benefit amount. There are different schedules for different types of employees.

 

Libido

This refers to a person's sex drive, interest in sex.

 

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 or entity you would like the money to go to after your death. Employers may offer this as a benefit to their workers but it is also available without any employer relation. 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 refer to the limits of your plan coverage. 

 

Lipids

These are fats in the blood. Lipids and protein help fuel the body. Cholesterol and triglycerides are types of lipids. They need to be checked regularly. High levels can be dangerous. They can build up in your blood vessels and arteries and lead to a heart attack and stroke.

 

LTD

This term refers to Long Term Disability. Employees may suddenly have to face a chronic 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 benefits outside the LTD plan may reduce the amount payable under an LTD plan. 

 

LTD pension accrual

This is applicable to employees 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. 

 

LTD pension supplement

This is applicable to employees 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.

 

Long-term care insurance

Long-term care services are costly. Health plans, disability insurance and Medicare might not help much as 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. It 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.

 

Lock-back period

This is mostly used 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 5 years, people must list all conditions they had or were treated for in the last 5 years. If the list is wrong or has certain health problems on it, the company can deny coverage. They can also approve and request 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.

 

Loss ratio

The ratio of total claims paid plus administrative expenses (in the case of third-party administrators) incurred divided by the total premium collected from subscribers and the organization for a specified period. A ratio of 1.0 or under is favourable since it means that total premiums collected are sufficient to cover the total cost of the programme. A ratio of over 1.0 means that the total premiums collected are not adequate to cover the cost of the programme.

 

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.

 

M

MA Plan

This is a type of Medicare Advantage plan. It does not cover prescription drugs.

 

MA-PD plan

This is also a type of Medicare Advantage plan. It covers prescription drugs.

 

Mail-order pharmacy

People can get prescription drugs through the mail with this service. 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.

 

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 term applies to a type of tumor. It means the tumor is cancerous and can grow and spread in the body. 

 

Managed Care

This is a type of health plan based on an agreement with doctors and hospitals to form a network. Plan participants 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 network for care. The plan may also require preapproval of some services.

 

Managed Care Company

This term refers to a health insurance company. 

 

Mandated benefits

These are the benefits that health care plans must provide. State or federal law require them.

 

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 refers to the maximum amount of time employees can receive a benefit amount through their disability plan. 

 

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 plan participant'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

This refers to a state government program. It provides health care coverage. It is meant for people with low incomes and includes families and children.

 

Medical Condition

This refers to a disease, illness or health problem for which you should seek treatment.

 

Medical information

Any information acquired by medical personnel, whether orally or in writing, relating to the physical or mental condition of any individual covered under a health insurance plan. For purposes of the proper review and administration of claims, such information may include, but not be limited to, diagnosis, physician’s medical reports, results of diagnostic tests, treatment plans, prescriptions, etc. 

 

Medical management/pre-certification

Processes whereby the administrator of the medical plan is contacted before certain services, such as hospitalization and outpatient surgery, are provided.

 

Medical necessity

All health-care services (that is, procedures, treatments, supplies, devices, equipment, facilities or drugs) that a medical practitioner, exercising prudent clinical judgment, would provide to a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the covered individual’s illness, injury or disease; (c) not primarily for the convenience of the covered individual, physician or other health-care provider; and (d) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered individual’s illness, injury or disease. 

 

Medical net salary 

The remuneration of a staff member that is used as the basis for calculating his or her MIP contributions. It consists of gross salary less staff assessment plus any language and non-reseident's allowance. The remuneration is that which appears on the salary scale for the month in question, at the grade and step of the staff member, including temporary grade and special post allowance.

 

Medicare

This is a program of the federal government. It provides health care coverage. It is for people:

• age 65 or older
• with certain disabilities
• who have permanent kidney failure, with dialysis
• transplant

 

Medicare Limiting Charge 

This applies to a health care provider that does not participate in Medicare. Thus, 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 that:

• strengthened the current Medicare program
• added coverage for preventive care 
• created the Medicare Part D prescription drug plan
• provided support to people with low incomes

 

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:

• inpatient care at a hospital 
• medical care at a Skilled nursing facility
• hospice care
• Home Health Care

The plan has limits. People must also pay deductibles, copays and other costs.

 

Medicare Part B

This is part of the original Medicare plan managed by the federal government. People have to actively sign up for this plan and usually pay a monthly premium. It covers:

• Necessary services from doctors
• Outpatient care from a hospital
• Physical therapy (partially)
• Occupational therapy (partially)
• Home Health Care (partially)

 

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 plans. These plans can be:
Health maintenance organizations
Preferred provider organizations
Medicare Private Fee-for-Service plans.

When people use doctors and hospitals in the plans networks, they might pay less.
Some of these plans cover prescription drugs and are called MA-PD plans. Some do not cover prescription drugs and are referred to as MA plans. 

 

Medicare Part D

This is an optional Medicare plan. It provides coverage for some prescription drugs. It can be offered as part of a Medicare Advantage plan in which case it is referred to as MA-PD or  separately from the Medicare plan in which case it is called a Medicare prescription drug plan or  PDP. 

 

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 that 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 refers to the type of drug a person takes. It can be a prescription drug or an over-the-counter drug.

 

Member

A member is someone who belongs to a health plan. Members are also referred to as enrollees or plan participants.  

 

Member Services

This is a department in a health plan company. It helps people understand how their health plan works. Member Services refer to the following:

• phone consultations
• provision of plan documents 
• replacement of member ID cards

People usually find the phone number for  Member Services on their ID card. 

 

Membrane 

This is a thin, flexible layer of tissue. It covers or connects a part or area of the body.

 

Menopause

Women in this stage of life no longer get their period.

 

Menses

This refers to a woman's period.

 

Mental Disorder

This refers to 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 dont show up on blood tests or X-rays.

 

Metastatic (metastize)

This term refers to cancer that has spread.

 

Methodology

This refers to 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. It 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. 

 

MIP reference salary

The monthly net base salary at the top step of the highest regular General Service level of the duty station scale. For this purpose, any extended General Service or National Professional Officer levels are not taken into account nor are longevity or long-service steps. The MIP reference salary is based on the scale in use on 1st Januar each year and is not revised on the basis of subsequent salary scale revisions unless such revisions have a retroactive effective date prior to the reference date. In cases where a grandfathered salary scale is in effect in the duty station, the scale to be used is the one that results in a higher MIP reference salary. 

 

Modify

This is a synonym for change. For example, a doctor suggests that you modify your diet. That means they want you to change the way you eat.

 

Monitor

This is a synonym for keeping track of something. For example, a doctor wants to monitor your blood pressure. That means they want you to watch it for a period of time to make sure there is nothing wrong.

 

Monthly Benefit

This is applicable to 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.

 

Monthly plan premium

This is the payment you make every month to a health plan. You are paying for the health insurance coverage the health plan provides.

 

N

Nasal Congestion

This is a term used to describe having a '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:

• indemnity plans
• the out-of-network part of managed care plans
• emergency or necessary services not provided by the network.

*Aetna does not credential, monitor or oversee those providers who participate through third-party contracts. Since there are a number of factors that determine whether a discount will be given, Aetna is unable to guarantee any level of discount under this program.

 

NCQA

This term refers to the National Committee for Quality Assurance which is an US-independent, nonprofit group. The NCQA  has an official recognition process. It measures how well a health plan:

• manages its care delivery system
• improves health care for members

 

National Medical Excellence Program

This is an Aetna program. It helps plan participants get covered treatment for:

• solid organ transplants
• bone marrow transplants
• some other rare or complex conditions

The services must be done by in-network facilities. They must have experience in these areas.

 

Nausea

This refers to a feeling of sickness in the stomach.

 

Necessary (in health plan contexts)

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. Other terms used in this context are medically necessary, medically necessary services or medical necessity.

 

Neglect

This means not taking care of something.

 

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  provider to provide services. Usually, the network provides services at a special rate. With some health plans, people get more coverage when they get in-network care.

 

Nocturia

This is a medical condition. A person who has it gets up often during the night because he or she needs to urinate.

 

Non-occupational disease

This describes a disease not caused by a job or in any way related to a job.

 

Non-occupational injury

This is an injury not caused by a job or an act related to a job.

 

Noncancerous

This refers to a condition that is not cancerous.

 

Noncontributory

This is the cost of a group insurance plan that is paid by an employer. It can be part of the cost or the entire cost. 

 

Nonparticipating provider

This is a health care provider who does not have a contract with a health plan provider (out-of-network). People might pay more when visiting this kind of doctor, hospital or other health care professional. 

 

Nonprescription

This refers to drugs a person can buy without a prescription.

 

Nutrient

This is a substance that is good for the body. The term is mostly used in the context of food.

 

O

Occupational injury/disease

This is an injury or disease that occured during an assignment. In most states, this is covered by workers' compensation.

 

Occupational therapy

People can lose 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 participants see a participating provider without referral. In other words, they give open access. This might also be called direct access.

 

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.

 

Opt-out Doctor

This refers to a doctor that does not accept Medicare coverage. 

 

Optimum

This term refers to something being most favorable or best.

 

Oral

This refers to anything consumed or given by mouth.

 

Oral and maxillofacial surgeon

This dental surgeon provides treatment in and around the inside of the mouth and jaws.

 

Original container

This refers to the bottle or box something comes in.

 

Orthodontist

This is a type of dental specialist. This specialist finds, prevents and corrects problems related to how teeth are positioned in the jaws.

 

Osteoporosis

This is a medical condition. A person with this condition has soft, brittle bones.

 

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 or offsets/reductions. Social Security Disability and workers' compensation are two examples. 

 

Out-of-network

This means that your health plan provider does not have a contract for reduced rates with a doctor. They will not know exactly what an out-of-network doctor will charge. If you choose a doctor or other health care provider who is out-of-network, your health plan may pay some of that doctor's bill. But it will pay less than if you get care from a doctor in-network. You will pay more money if you decide to use a doctor that is not in-network. Please check your plan documents for more details.

 

Out-of-pocket expenses

The unreimbursed portion of recognized medical expenses (or co-insurance) that are taken into account in determining the application of the hardship provisions. 

 

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

Services provided to a person in a clinic, emergency room, hospital, medical or surgery centre or other facilities that do not involve an overnight stay in the facility. The patient receives care and returns home without being admitted. 

 

Outpatient procedure

Some procedures can be done in a hospital, surgery center or a doctors office.  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.

 

P

Palliative Care

Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illnesses.

 

Partial day treatment

This is a behavioral health program. It 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 income earned before he or she became disabled.

 

Participating pharmacy

This is a pharamacy that has a contract with a health plan provider. It fills covered prescriptions for plan members. Plan participants 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 (also called in-network provider).

 

Participating survivor

An eligible family member who survives a subscriber. 

 

Patient

This is a person who gets medical care. The care is provided by a doctor, hospital or other health care provider.

 

Pediatric dentist

This dentist treats children. Sometimes, this dentist is also 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 staff. An employer pays for or contributes to the fund as part of a benefits package.

 

Periapical

This is the area and tissue around the root of a tooth.

 

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 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 and is usually stored online. A health plan can add to it by adding 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 also called 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 persons share for covered prescription drugs. It is paid to a participating pharmacy. It is a set dollar amount.

 

Physical reaction

This describes how the body reacts to something.

 

Physical therapy

This is care given to help improve parts of the body. It helps ease pain and promote healing. It can also help prevent disability. It is also used after illness, injury or surgery.

 

Physician

A person who is licensed to practise medicine by the authorities responsible for the territory in which he or she is practising.

 

Placebo

This is a substance that has no actual medicine in it. It is also called a sugar pill. It can be given to help people feel better. However, it is usually used during tests to find out how potential new drugs and treatments will work.

 

Plan documents

The papers provided by a health plan provider are referred to as plan documents that describe the details of coverage. They include:

• group agreement
• group policy
• certificate or evidence of coverage or certificate of insurance
• summary of coverage or benefits

 

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.

 

Plaque

A plaque is a soft, sticky substance on the teeth. It comes from bits of food and bacteria in the mouth. It can be removed by brushing and flossing. If it is not removed, it can cause cavities and gum disease.

 

POS

A point of service (POS) plan is a type of managed care health insurance plan in the United States of America. It combines characteristics of the health maintenance organization (HMO) and the preferred provider organization (PPO). It provides health-care services at a lower overall cost. The United Nations POS plan with Aetna also allows plan participants to visit any in-network physician or health-care provider without first requiring a referral from a primary care physician. 

 

Policy holder

This is a person or entity that has a contract with an insurance company.

 

Portability

This is a legal right of an insured person under which the person still gets to keep group insurance. As it is kept as an individual policy, the person does not need to prove he or she is in good health to keep the policy.

 

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:

• clinical practice guidelines
• practice parameters
• medical protocols

 

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 plans coverage began.

 

Precertification

This is an important process that refers to the approval a person gets for care before they receive the respective care. This helps people to determine whether the care is covered by a health plan. Plan participants should check in their plan to see what kind of service require this approval. It can also be called: 

• precertification*
• authorization
• certification
• prior authorization

*In Texas, this approval is known as pre-service utilization review and is not verification as defined by Texas law.

 

PPO

A preferred provider organization (PPO) is a medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates. PPO medical and health-care providers are known as “preferred providers”. PPO plans allow participants to visit any in-network physician or health-care provider they wish without first requiring a referral from a primary care physician. 

 

Premenstrual

This term refers to the time prior to the on-set of a woman's period.

 

Premium waiver

This term refers to a contractual condition that means that an insurer can keep up life insurance coverage for a disabled employee. The employee does not pay for the coverage.

 

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.

 

Prescription drug

This is a type of drug that requires a doctor's prescription before it can be sold. It is different than an over-the-counter drug which can be bought without a prescription.

 

Prescription

A doctor's order for a drug is called a prescription. It is usually written. If it is a verbal order, it must be put in writing by the pharmacy.

 

Prevailing charge

This refers to a limit on the amount your health plan will pay.  It is also called "usual, customary and reasonable (UCR)," "customary and reasonable" (CnR) or "reasonable" charge.  The limit is based on data showing the average charge for the provided health care service.
 
 

Preventive care

This type of care is usually covered. It includes programs or services that can help prevent disease such as yearly exams, shots and tests.

 

PCP

This term refers to the primary care physician which is a doctor that is part of a health plan's network. The PCP 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.

 

Prior creditable coverage

This term refers to types of health coverage a person has had. People sometimes need to provide proof of it to be fully covered by a new plan. 
 

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 that enables them to visit any doctor or hospital that is both:

• approved by Medicare
• accepting the plan's payment and other terms

 

Prognosis

A description of the likely course of a disease or illness provided by a physician, including the patient’s chances for recovery. 

 

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 and hands.

 

Prosthodontist

This is a type of dentist that restores or maintains dental health by replacing natural teeth. A person might see this specialist for dentures.

 

Provider

This term is frequently used often in health plans. It refers to a licensed person or place that delivers health care services. Some examples are doctors, dentists, hospitals and more.

 

Pulmonary embolism

This is a blood clot in the lungs.

 

Q

Quadrant

Dentists often use this word to describe the area of the mouth they are working on. The mouth has four equal sections, or quadrants. They are the upper right, upper left, lower right and lower left. Picture a straight line between the center of the teeth to the back of the mouth. That is the division point. For example, a lower left molar would be in the lower left quadrant.

 

Qualified medical expenses 

This term refers to costs paid for health care that people can deduct from their taxes. For a complete list, see Section 213(d) of the Internal Revenue Code.

 

Qualifying event

This is an event that lets a member change his or her health benefits. Examples include death, job loss, divorce and marriage.

 

R

Radiation therapy

This is a treatment used to fight cancer. High-energy rays damage cancer cells so they stop growing.

 

Reasonable and customary (RnC)

The prevailing pattern of charges for professional and other health services at the staff member’s duty station or the approved location (for example, the place of approved medical evacuation or regional area of care) where the service is provided. 

 

Reasonable charge

This is a limit on the amount your health plan will pay. Also called "usual, customary and reasonable" (UCR)," "customary and reasonable" (CnR) or "prevailing" charge. The limit is based on data regarding what doctors' charge for the health care service. 

 

Reasonable occupation or job

This term refers to a paid occupation or job a disabled person can get through training or skill.

 

Rebase

This term refers to a procedure in which the entire base of a denture is replaced without changing the teeth.

 

Recognized charge

This refers to a limit on the amount your health plan will pay.  It is also called the "allowed amount".  If you choose to visit out-of-network providers, 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 co-pays and deductibles.

 

Recognized expenses

The expenses for services claimed, provided they are found to be reasonable and customary at the duty station or, when obtained elsewhere in the country or at an approved medical evacuation location or regional area of care, at the place provided. If the expenses claimed are found to be above what is considered reasonable and customary, then the recognized amount for the purpose of calculating reimbursement is the reasonable and customary amount as reasonably determined by the third-party administrator. 

 

Recurrent disability

This means that 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 provides you with in order for you to get care from a specialist or health care facility. It may be written or sent by computer.

 

Regional Area of Care (RAC)

For each country with inadequate medical facilities, the UN MIP has established a ‘regional area of care’, i.e. a specific neighbouring country or region designated by the UN, where staff members can seek medical treatment without requesting approval for a medical evacuation. Medical expenses incurred in such areas will be reimbursed up to the limits of reasonable and customary expenses of the country where the treatment or service is provided.

 

Rehabilitation engineering

This is done to help disabled people live better. It can help them do their job. It can also help them in community and daily life activities. Examples are building a wood ramp for a wheelchair or providing a computer that responds to a voice. 

 

Rehabilitation program

This is a program that helps a person improve his or her health so he or she can return to work. Physical, mental and career training is used.

 

Reimbursement

This refers to the money you get back from your health plan for covered costs you paid to your doctor.

 

Related absences 

This refers to a situation in which an employee is out of work for at least two recurrent times in case they are out for the same health problem each time.

 

Reline

This refers to the procedure of a dentist resurfacing part of a denture to make it fit better.

 

Renewal

This refers to the continuance of an insurance policy with adjusted terms such as new rates. 

 

Respiratory therapy

This treatment brings dry or moist gases into the lungs.

 

Respite care

This is care that gives families a short break from the duties of constant care.

 

Retiree

This applies to staff who has retired from working. To be considered a retiree, the former staff must meet the employers rules for minimum age and years of service.

 

RRA

This term refers to the retiree reimbursement account which is a type of account people can use after they have retired. It can help pay for health plan premiums and medical costs after 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.

 

RTW incentive

RTW is used to refer to Return-to-work. The RTW incentive lets workers who were disabled return to work on 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 refers to the chance or likelihood of loss.

 

Rollover feature

This feature 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.

 

Root canal

This refers to the space in the center or canal of the tooth that contains the pulp and the root of the tooth. A root canal treatment takes red or infected tissue out of the canal of the tooth root. Then, the empty canals are cleaned and sealed so the tooth does not have to be pulled.

 

Root planning and scaling

This refers to the procedure of a dentist removing buildup under the gum line. It smoothes the surface so bacteria cant form as easily.

 

Rx

This symbol is used to refer to a prescription or pharmacy.

 

 

 

S

Salary continuation

This applies 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 what a policy does and does not cover.

 

Second (surgical) opinion

This refers to an opinion you get from a second doctor. You might 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.

 

Section 213(d)

This is part of the Internal Revenue Code. It lists what type of medical expenses people can deduct from their taxes. It applies to plans with an FSA, HRA, HSA or MSA. 

 

Self-insured employer

This refers to an employer who pays benefit claims for their staff. 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. It 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 as the employer is oftentimes not subject to state law requirements.

 

Service area

This refers to an area served by a health plan such as eligibility and provider network. 

 

STD

This refers to Short-term disability benefits which are paud when an employee is out of work. The employee 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 provides you with 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 usually cannot be renewed.

 

Sickness

This refers to a condition for which you would need medical care.

 

SNF

This term refers to a skilled nursing facility which is a place that gives nursing care to people who do not need to be in a hospital. It is licensed and provides rehabilitation services btt does not include nursing homes or care for those who need help with daily living.

 

Small business health insurance

This refers to health insurance for companies that have 2 to 50 employees. These plans help employers save on their taxes. They also help employees save on their premiums.

 

Social Security retirement benefits

This is a retirement program run by the US 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.
Age 62 is the earliest age to receive Social Security. Employers decide the age when a person can receive full benefits. If a person has earned more money in their life, checks may be higher. If they have earned less, their check amount may be lower.

 

Special benefit networks

These are groups of doctors, specialists or health centers. They provide care for special services such as mental health and drug abuse.

 

SEP

This term refers to the special election period for people with a Medicare plan. It is a period when they can change their benefits because something in their life changes. Examples would 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.

 

SNP

This term refers to the Special needs plan which is a Medicare Advantage HMO or PPO plan. It is applicable to 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 condition that is disabling.

 

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 therapy

This is a treatment to fix something that is wrong with a person's speech. The problem could have started from birth or could ave been from a disease, an earlier medical treatment or a former injury.

 

Staff model

This is a type of HMO plan. Doctors who give care are staff of the HMO. This is different from an independent practice association (IPA) HMO. In an IPA-model HMO, the doctors who give care are not staff of the HMO. 

 

SIC

This term refers to the standard industrial classification which is a system the US government uses to classify, or group, industries. They are grouped by their products or services.

 

State insurance department

This is an agency that makes state insurance laws. It also ensures that insurance companies follow the laws in their state.

 

State-mandated benefits

These are benefits a state requires in a policy. If the benefit is not in the policy, the policy cannot be sold in the respective state.

 

Step therapy

This is a way that a health plan controls drug costs. It requires that a person tries certain drugs before a particular brand-name drug will be paid for by the plan. 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 exceed 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 the plan is a family health plan, the person can add people to it as dependants. Those people must be eligible to be added. 

 

Successive disabilities

This is the case when a person experiences disability for at least two times due to the same condition or a related condition. Each episode is separated by a time period that is stated in the contract.

 

Supplemental life insurance

This is an additional life insurance. Any staff can buy this to get more than the basic amount offered by their employer.

 

SMI 

This refers to the supplemental medical insurance which is also called Medicare Part B. This insurance covers basic medical needs and is paid by both the insured person and the government.

 

Subscriber

An active or after-service participant enrolled in the United Nations health insurance programme or, upon the death of the former or the latter, the surviving spouse (if any) or the eldest eligible child recognized and receiving a monthly benefit from the United Nations Joint Staff Pension Fund. 

 

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 must be on the policy. 

 

T

Temporary partial disability

This is an employee benefit. It offers limited pay to employees who are back at work, but cannot perform their regular job. An employee can receive this only if they were injured on the job.

 

Temporary total disability

This is an employee benefit. It offers limited pay to employees who cannot work at all. An employee can receive this only if they were injured on the job.

 

TMJ

This refers to the temporomandibular joint which is a joint that connects the jaw to the skull. There are two of themwith each sitting in front of an ear. 

 

TMD

This refers to temporomandibular joint disorder which leads to 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 refers to specialized medical care. It involves complex procedures. People usually need this care for a long time. The care is usually provided by specialists in state-of-the-art medical centers.

 

Third-Party Administrator (TPA)

An outside entity engaged by the United Nations for the processing and payment of United Nations health insurance programme claims.

 

Total disability (any occupation)

This refers to a state in which a person cannot perform any occupation due to illness or injury. It is determined by factors 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.

 

Transferable skills analysis

This test helps people find a new job when they can no longer perform their current job due to illness or injury. The employer would look at skills, education and other activities of their employee to then match them with a position the employee is more likely to be able to handle. 

 

U

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. 

 

Underwriting

This process helps assess the costs of insuring potential members and is used to determine eligibility. Applicants may be asked medical questions or required to provide a health exam certificate. Rate level and premiums will be based on these results.

 

Urgent care

Urgent care is not the same as emergency care. Urgent care is applicable if a person experiences a sudden illness or injury that is not life threatening but requires immediate assistance to avoid more serious pain or issues. 

 

UCR

This term refers to usual, customary and reasonable care which is a limit on the amount your health plan will pay. It is also called "customary and reasonable," "reasonable "or "prevailing charge". The limit is based on data of average provider charges for health care services. 

 

V

Vocational evaluation

This helps to rate how willing and able a person is to return to work. It also shows how well he or she will relate to managers and coworkers. A formal evaluation is based on standardized tests and direct observation of the worker doing job tasks and conducted at a rehabilitation center. An informal evaluation is usually conducted in form of an interview by a private job counselor.

 

Voluntary plans

These are group benefits offered by the employer. They are completely paid for by staff.

 

W

W-2

This form is used to report a person's income to the Internal Revenue Service (IRS).

 

Weekly benefit

This refers to the amount of weekly payments an employee can receive while out of work on disability. It is subject to the terms of the insurance policy or plan document for the group short-term disability plan. 

 

Well baby care

This refers to the routine care a baby or child needs through the age of eight. It includes checkups, tests and shots.

 

Well woman care

This is the regular care a woman needs. It includes checkups with the OB/Gyn and regular pregnancy care.

 

Wellness programs

These programs assist people in staying health and may include ways to prevent disease, stay fit and learn how to care for one's own health. 

 

Work adjustment

This can help workers improve their skills and attitude on the job. Workers may get formal counseling or receive supervision while doing job tasks in a rehabilitation center. This often applies to employees who have not worked for a long time or employees with learning or psychiatric challenges. 

 

Work hardening

Employees usually commence this program after physical therapy but before their return to work. It usually lasts for 2-4 weeks and 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 with a confirmed job availability. 

 

Workers compensation

This covers employees hurt on the job. Under this law, they are entitled to receive payments for medical costs and disability pay. It is available in all 50 states, American Samoa, Guam, Puerto Rico and the U.S. Virgin Islands.

 

X

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.