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Second Opinion
This is when another doctor gives his or her view about what you have and how it should be treated.
Self-insured
The self-insured employer assumes risk for health care expenses in a plan that is self-administered or administered through a contract with a third-party organization. This form of coverage is regulated by the Employee Retirement Income Security Act of 1974. Hence, self-insured health plans fall under federal, rather than state, regulation.
Service Area
The area where a health plan accepts members. For HMOs, it is also the area where services are provided. A health plan may terminate coverage for persons who move out of the plan's service area.
Skilled Nursing Facility
A licensed institution that provides regular medical care and treatment to sick and injured persons. Daily medical records are kept and patients are under the care of a licensed physician.
Special Benefit Networks
Provider networks for particular services, such as mental health, substance abuse, or prescription drugs.
Staff Model
Staff model is a type of HMO in which care is provided by physicians who are employees of the HMO. This contrasts with the "independent practice association (IPA)" HMO, in which independent physicians contract with the HMO.
State Insurance Department
An administrative agency that implements state insurance laws and supervises (within the scope of these laws) the activities of insurance companies operating within the state.
State-Mandated Benefits
Benefits for a variety of medical conditions that a given state requires of health insurance policies sold in that state.
Stop-loss Provisions
A limit in a health insurance policy that provides for 100% payment of expenses after total patient out-of-pocket expenses exceed a certain contractual dollar amount.
Third-Party Payer
Any payer of health care services other than the insured person. This can be an insurance company, HMO, PPO, or the federal government.
Treatment Options
The choices you have when there is more than one way to treat your health problem.
Underwriting
The act of reviewing and evaluating prospective insured persons for risk assessment and appropriate premium.
Unforeseen Out-of-Area Urgently Needed Care
Care you get for a sudden illness or injury that needs medical care right away, but is not life threatening, while you are out of your health plan's service area for a short time, and can not wait until you return home.
Urgently Needed Care
Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care.
Usual and Customary (U&C) Charge
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. "Usual and Customary (R&C)" essentially means the same thing as "Reasonable and Customary (R&C) Charge."
Utilization Review
A mechanism by which the appropriateness, necessity, and quality of health care services are monitored by both insurers and employers.
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