Insurance terms

También llamados planes Obamacare, son pólizas de seguro médico que cumplen todos los requisitos de cobertura establecidos en la Ley de Asistencia Asequible de 2010. Esta amplia ley de reforma sanitaria estableció nuevas normas para los seguros con el fin de proteger mejor a los consumidores. Todos los planes de la ACA deben ofrecer prestaciones sanitarias esenciales, cubrir enfermedades preexistentes, no tener límites anuales/vitales en dólares y cumplir otros requisitos. Esta cobertura de calidad mejorada viene acompañada de un mandato individual de tener seguro o enfrentarse a una multa fiscal.

Seguro complementario que cubre los gastos si sufres una lesión inesperada a causa de un accidente, como huesos rotos por un choque en bicicleta, conmociones cerebrales en la cancha de baloncesto, quemaduras por un percance en la cocina, etc. El seguro de accidentes ayuda a cubrir las costosas facturas médicas, los gastos de ambulancia o las bajas laborales no remuneradas para recuperarse que tu seguro médico habitual puede no cubrir.

Se trata de equipos sanitarios que trabajan juntos para ofrecer una atención coordinada, con el objetivo de mejorar la calidad y reducir los costes compartiendo responsabilidades y recompensas.

Estos profesionales utilizan estadísticas y análisis para calcular riesgos y prever costes futuros. Las compañías de seguros médicos confían en los actuarios para que hagan números con los datos históricos de siniestros y las tendencias sanitarias para predecir con exactitud los gastos futuros. Esto orienta la fijación de precios y garantiza que se cobre por adelantado una prima suficiente para cubrir las próximas facturas médicas que puedan surgir aleatoriamente.

Un perito de seguros es la persona encargada de evaluar un siniestro de seguros para determinar si la compañía de seguros debe pagar el siniestro en cuestión y cuánto debe pagar. Un perito puede ser un representante de la compañía de seguros o puede ser independiente. Un reclamante también puede contratar a un perito público para que realice su propia investigación sobre el siniestro, al margen de la compañía de seguros.

Se trata de un acuerdo entre médicos y hospitales que permite a los médicos admitir pacientes en ese hospital para recibir tratamiento o atención médica.

Estas conversaciones tienen lugar entre los profesionales sanitarios y las personas para determinar las preferencias de atención médica futura. Incluye conversaciones sobre los deseos de atención al final de la vida, garantizando que la atención sanitaria se ajuste a los valores y deseos de la persona.

Las voluntades anticipadas son un documento legal que permite a las personas expresar sus deseos en materia de asistencia sanitaria. Puede incluir instrucciones sobre tratamientos de soporte vital y la designación de alguien que tome decisiones sanitarias en su nombre si no puede comunicarse.

Puede tratarse del primer pago o pago vinculante de una póliza de seguro, o puede ser un pago efectuado antes del primer pago previsto de una póliza que la compañía de seguros pone a disposición del tomador del seguro, normalmente, por un descuento o como parte de una promoción.

Esta subvención gubernamental ayuda a reducir el coste de las primas del seguro de enfermedad de las personas o familias con rentas más bajas que reúnan los requisitos necesarios.

Con respecto al seguro de enfermedad, una determinación adversa de prestaciones se refiere a una situación en la que la compañía de seguros deniega una prestación, rechaza el pago de un servicio ya recibido o rescinde la cobertura sanitaria.

La selección adversa es una situación en la que quienes prevén necesitar más servicios sanitarios son los que contratan el seguro. Puede dar lugar a grupos de riesgo desequilibrados y costes potencialmente más elevados para las aseguradoras, lo que afecta a la estabilidad de los planes de seguros.

La ACA es una ley de reforma sanitaria integral cuyo objetivo es mejorar la accesibilidad, asequibilidad y calidad de la asistencia sanitaria en Estados Unidos. A veces conocida como Obamacare, introdujo medidas como mercados de seguros médicos, subvenciones y protecciones contra la denegación de seguros por enfermedades preexistentes.

En sanidad, un agente es una persona con licencia que ayuda a encontrar y comprar planes de seguro médico que se ajusten a las necesidades de una persona. Ayudan a los compradores a navegar por las distintas opciones de seguros disponibles en el mercado.

Se trata del importe máximo en dólares que una aseguradora sanitaria se compromete a pagar por cualquier servicio médico, tratamiento, prueba, etc. Todo lo que supere esta tarifa acordada se facturará a los pacientes como "facturación de saldo". Las negociaciones de tarifas entre los proveedores sanitarios y las aseguradoras establecen las cantidades permitidas para cada servicio cubierto, desde una visita médica de 15 minutos hasta una operación de trasplante de órganos.

Este paquete legislativo proporcionó alivio económico durante la pandemia de COVID-19. Incluía medidas para ampliar y aumentar los subsidios para los planes de seguro de salud bajo la ACA, reduciendo los costos para muchas personas y familias.

Se refiere al importe máximo que un plan de seguro pagará por los servicios cubiertos en un año. La ACA prohibió a la mayoría de los planes de seguro médico imponer límites anuales a las prestaciones sanitarias esenciales para garantizar una cobertura adecuada a las personas.

Si la compañía de seguros deniega una solicitud, el asegurado puede pedir que la examinen de nuevo y reconsideren su cobertura. Presentar un recurso formal con pruebas de su médico le permite impugnar la decisión de su aseguradora. Los planes de salud deben describir el proceso de apelación, que empieza con una revisión interna y puede escalar a terceros externos o a un tribunal. Los recursos le permiten defender su derecho a una cobertura justa.

Por lo que respecta al seguro de enfermedad, la solicitud es un formulario que facilita a la aseguradora determinada información necesaria para suscribir los riesgos de salud de una persona. Suele adjuntarse al contrato de seguro como parte del "contrato completo".

Estos planes permiten a las pequeñas empresas o autónomos unirse para contratar un seguro médico. Su objetivo es darles acceso a una cobertura más asequible aprovechando el poder adquisitivo de un grupo mayor.

Alguien que usted elija para actuar en su nombre ante el Mercado, como un familiar u otra persona de confianza. Algunos representantes autorizados pueden tener autoridad legal para actuar en su nombre.

Es la cantidad que un proveedor de asistencia sanitaria cobra a un paciente por la diferencia entre lo que cubre su seguro y el coste de los servicios prestados.

Se trata de un plan que se utiliza como punto de referencia para determinar el nivel de cobertura y los costes del seguro de enfermedad ofrecido en una zona determinada.

Los beneficiarios reciben ventajas o pagos de una póliza de seguro, como en el caso de una persona cubierta por un plan de seguro médico. Los beneficiarios pueden tener cualquier seguro médico, incluidos Medicare, Medicaid o una cobertura privada.

Algunos planes limitan la cobertura de los tratamientos o servicios sanitarios fijando un tope al número de visitas o al importe en dólares que pagarán por ellos al año. Por ejemplo, un asegurado puede encontrar un tope duro después de 20 sesiones de quiropráctico o 30 citas de fisioterapia al año. Otros límites podrían restringir la cobertura de los tratamientos de infertilidad de alto coste. Aunque el objetivo de los límites de prestaciones es evitar la sobreutilización, saber qué servicios críticos tienen límites puede ayudar a los compradores a elegir la mejor póliza de seguro.

A diferencia del año natural, que empieza de cero el 1 de enero, el año de prestaciones se basa en la fecha de inicio del plan. Este ciclo de 12 meses sirve de base para todos los elementos de una póliza, desde las franquicias, los desembolsos máximos y los medicamentos cubiertos hasta los proveedores de la red, entre otros. Esencialmente, es la forma en que las compañías de seguros llevan la cuenta de los costes acumulados de una persona y de los datos de inscripción a lo largo del tiempo. ¿Cambiar de plan a mitad de año? Comprender el año de prestaciones le proporcionará información sobre los cambios que puede esperar.

En el contexto de los seguros, una cartera de negocios es una base de datos o "libro" en el que figuran todas las pólizas de seguros que la compañía de seguros ha suscrito o completado.

Se trata de medicamentos con nombres exclusivos protegidos por patentes, como Vyvanse para tratar el TDAH o Keytruda para distintos tipos de cáncer. A pesar de su elevado precio, se anuncian directamente a los pacientes porque aún no existen equivalentes genéricos que puedan competir con ellos. Ser el único en las estanterías da a los medicamentos de marca la ventaja de cobrar más y maximizar los beneficios durante el periodo de protección de la patente. Esto contribuye al aumento de las primas de los seguros. Si prefiere los medicamentos de marca a los genéricos, prepárese para pagar copagos o coseguros elevados.

Los corredores son como los casamenteros de los seguros. Ayudan a los compradores a encontrar y contratar el plan de seguros adecuado a sus necesidades.

Se trata de uno de los niveles de planes de seguro médico de la ACA y suele ofrecer primas mensuales más bajas pero gastos de bolsillo más elevados por los servicios sanitarios.

Los planes combinados reúnen distintos tipos de cobertura, como la sanitaria, la dental y la oftalmológica, en un único y práctico plan.

The Consumer Operated and Oriented Plan program, or CO-OP, is designed to provide nonprofit, member-governed health insurance options.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers and their families to continue their employer-sponsored health insurance coverage temporarily after leaving a job, usually at a higher cost.

With respect to health insurance, a cancellation refers to the termination of the insurance policy or coverage either by the insurance company or the insured person before the end of the period of coverage.

This type of insurance provides financial support if someone is diagnosed with cancer. It helps cover treatment costs, including medical bills, medications, and other related expenses.

This alternative payment model is like a flat-rate subscription for healthcare services. Capitation is a payment method in which healthcare providers receive a fixed amount per patient to cover all necessary medical services. Primary care physicians or integrated hospital-insurer networks will manage total care for a large patient group under an agreed-upon capitated rate paid upfront on a monthly basis by associated health plans. This prepaid lump sum remains the same per member regardless of utilization levels or whether they are healthy versus battling complex diseases. By prepaying for expected care expenses based on large-scale projections, this system incentivizes efficient preventative services over costly acute treatments.

A carrier is another name for an insurance company that offers insurance coverage, manages policies, and pays for covered services.

When prolonged hospitalizations or complex chronic illnesses lead to intensive ongoing care needs, case management helps coordinate treatments with medical teams, health plan administrators, patients, and family caregivers. These patient-centered services aim to optimize recovery outcomes and quality of life while managing the runaway costs of ambulant visits, home therapies, community care referrals, special equipment acquisition, etc. Case managers help enhance continuity and reduce duplication and contradictions across multi-specialist providers.

These are high-deductible health plans designed for young or healthy individuals, offering minimal coverage but protection in cases of severe medical emergencies or accidents.

CMS is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.

Proof of a person’s current or most recent insurance policy details will come via this official document, usually provided when coverage ends or changes. It provides evidence that legally entitles you to enroll in another individual or group health plan without exclusions or waiting periods imposed based on preexisting conditions. Certificates list the start and end dates, covered dependents, prior payer contact info, policy numbers, etc.

Think of this as the membership card for an insurance policy. It is a document that confirms your coverage details, such as the type of insurance, coverage period, and benefits included.

CHIP provides low-cost health coverage for children in families who earn too much to qualify for Medicaid but cannot afford private insurance.

The claim is a request for payment submitted by a healthcare provider to an insurance company for services provided to a patient.

Since health insurance is a contract, it includes clauses. A clause in this context refers to the financial responsibility of the insurance company to the policyholder as stipulated in the contract.

A list of medications (formulary) which may limit drugs to specific physicians, patient care areas, or disease states via formulary restrictions.

Think of this as cost-sharing in a joint venture. It is the percentage of healthcare costs you share with your insurance company after you have paid your deductible.

In terms of insurance, a commission is a fee in a percentage of the premium that an insurance company pays an insurance agent in exchange for soliciting applications for insurance for the company.

A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.

A composite rate is an insurance premium based on the average risk profile of a group rather than the risk profile of an individual policyholder. A composite rate implies that all members of a particular group pay the same insurance premium for coverage.

Comprehensive coverage includes a wide range of healthcare services and treatments, offering extensive protection against various health issues.

Coordination of Benefits (COB) refers to the rules that determine the primary plan and the secondary plan when an insured has two or more policies covering the same risks. It prevents insurers from overpaying for claims.

Copayments are fixed amounts paid for specific services covered by insurance, often due at the time of service.

This involves sharing expenses between an insured person and their insurance company, including deductibles, copayments, and coinsurance.

A subsidy for eligible individuals or families to reduce out-of-pocket costs such as deductibles, copayments, and coinsurance. If you qualify, you must enroll in a plan in the Silver category to get the extra savings.

Every policy will list exclusions, or services they don’t cover. Certain prescription meds, alternative treatments, extremely high-cost new therapies, or experimental procedures will almost never be included. Say you want LASIK eye surgery? Most health plans strongly resist covering these vision enhancements as a "non-essential benefit.” Digging through exclusions upfront helps avoid unpleasant surprise bills later.

This term refers to the comprehensive list of medical care, tests, treatments, therapies, and services covered by your health insurance. Everything from preventive scans to complex surgery may fall under this umbrella, as long as it's deemed medically necessary.

Like a safety net for tough times, this insurance policy pays a lump sum or provides a benefit if the insured person is diagnosed with a serious illness such as cancer, stroke, or heart attack.

A deductible is an out-of-pocket fee that an insured needs to pay as part of their insurance coverage. If an insured has a loss, they need to pay up to their deductible limit first before their insurance policy will cover the rest of the damages.

This is a retirement plan in which an employer promises specific benefits upon retirement, often including healthcare coverage.

A claim denial occurs when an insurance company refuses to pay for specific services or treatments outlined in a claim.

This program offers discounts on dental services for an annual fee but does not provide insurance coverage.

Because dental care is usually not included in primary health insurance, purchasing supplemental insurance, such as a dental plan, is necessary. It helps cover the cost of dental care and treatments, including routine check-ups, cleanings, fillings, and more.

These are like the plus-ones on an insurance plan. Dependents, such as children or spouses, are covered by someone else's health insurance policy.

This term refers to one of the features available to all members of HealthBird. The digital medicine cabinet is a feature that allows our members to search, add, and keep track of their prescriptions, medications and supplements.

This is a healthcare model in which patients pay a monthly fee directly to a primary care physician for comprehensive primary healthcare services without involving insurance companies.

Policyholders usually pay their premiums in advance. However, insurance companies do not immediately account for these premiums in their earnings. Rather, they earn the premium at even rates throughout the term of the policy. Therefore, the portion of premium that applies to the expired portion of the policy becomes the earned premium. Similarly, the portion of premium received that applies to the remaining term of the policy becomes the unearned premium reserve.

Think of this as the express lane for insurance sign-up. It's a simplified process that makes it easier for individuals to enroll in health insurance plans without complex paperwork or hurdles.

Easy pricing refers to transparent and straightforward pricing structures for healthcare services or insurance plans, helping consumers understand costs easily.

This is the start date for a person’s insurance coverage. It's the date when your insurance policy becomes active and starts providing coverage for healthcare services.

This refers to the number of individuals who have successfully enrolled in a health insurance plan and have active coverage.

EHRs are electronic versions of patients' medical records containing information about their health history, treatments, medications, and more. They are accessible to healthcare providers.

EMRs contain patients' medical information as recorded by a specific healthcare provider or facility, aiding patient care within that practice or institution.

Eligibility requirements, in the context of insurance, are requirements that an individual must meet in order to qualify for an insurance policy.

An eligibility period is the time frame following the eligibility date, usually 31 days, during which potential members of a group may enroll in a benefits program, e.g. health insurance, life insurance, or disability insurance, without evidence of insurability.

An embedded deductible is a feature in family health insurance plans that allows each member to have their own individual deductible within the overall family deductible.

Both urgent care and emergency rooms provide medical care, but they serve different levels of urgency. The emergency room is for life-threatening emergencies that require immediate medical attention, such as chest pain, difficulty breathing, severe bleeding, broken bones, head injuries, seizures, and poisoning. It provides a wider range of services than urgent care, including CT scans, MRIs, surgery, and intensive care, but has longer wait times and higher costs. The emergency room is open 24/7.

It's a provision under the ACA that requires certain employers to provide health insurance coverage to their employees or face penalties.

This is a penalty imposed on certain large employers if they fail to provide their employees with affordable health insurance that meets minimum coverage standards.

This is like a rulebook for employers regarding health insurance. It outlines the obligations and requirements for certain large employers under the Affordable Care Act to offer health insurance to their employees.

Tax credits are available to small businesses that provide health insurance coverage to their employees, helping offset the costs.

This refers to employers' health insurance plans, which typically provide group coverage at more affordable rates.

These are health insurance plans employers offer their employees, sometimes with multiple options based on individual needs.

An enrollment period is a specific time period during which a person can get health insurance, make changes in their policy, or qualify and apply for government subsidies.

Essential health benefits are a set of services that health insurance plans must cover, including preventive care, prescription drugs, and maternity care, as required by the ACA.

An exclusion refers to specific medical conditions, services, or treatments not covered by an insurance policy.

This is a statement sent by an insurance company to the insured person explaining the healthcare services provided, the amount paid by the insurance, and any remaining costs the patient owes.

The family glitch is a rule that prevents some families with employer-sponsored health insurance from receiving financial assistance for marketplace coverage. It happens when the employer's coverage is considered "affordable" for the employee, even if it's not affordable for the entire family. This makes marketplace coverage too expensive for many families, leaving them with limited options.

The FPL sets income thresholds used to determine eligibility for various healthcare programs under the Affordable Care Act (ACA). It helps decide who qualifies for subsidies, Medicaid, or CHIP by comparing household income to these set levels. In 2023, 400% above the FPL represents an income of $111K for one person or $228K for a family of four.

The FFM is an online platform the federal government runs where individuals and families can compare, shop for, and enroll in health insurance plans. It serves as a marketplace for different insurance options.

This is a payment model in which healthcare providers charge for each service or treatment they provide.

A fiduciary is a person who holds a legal or ethical relationship of trust with one or more other parties. Fiduciaries are persons or organizations that act on behalf of others and are required to put the clients’ interests ahead of their own.

A final internal adverse benefit determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function, or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a facility.

An FSA is a savings account you can contribute to from your paycheck before taxes. You can use this money for qualified medical costs like copayments, deductibles, and some over-the-counter items. Notably, FSAs are tax-free.

A drug formulary is a list of drugs approved by a health insurance provider, categorized by cost.

The Free Look Period allows you to review your insurance policy after purchasing it. If you change your mind within this period, you can cancel the policy and get a refund without penalties.

This is a measure employers use to determine whether they're required to offer health insurance under specific laws. It's calculated by adding up all the hours part-time employees work and converting them into the equivalent of full-time employees.

A gatekeeper is a healthcare provider who is the first point of contact for patients, and who decides what level of care the patient will get next. Oftentimes, primary care physicians are gatekeepers in the healthcare system.

General agents are insurance agents who sell insurance products to other insurance agents or brokers. The other insurance agents and brokers then sell these products to the people or companies who will be using the insurance. General agents act as insurance wholesalers as opposed to insurance retailers.

Once a brand-name drug's patent expires, other companies can offer the same medication at a lower cost as a generic drug. These alternative versions contain the same active ingredients and work just as effectively but without the hefty brand-name price tag. Choosing generic drugs is a smart way to manage your healthcare expenses while still getting the necessary medication.