Glossary of Insurance Related Terms

Schedule (Surgical)

A list of specified amounts payable for surgical procedures, dismemberments, ancillary expenses, and the like in hospital and medical reimbursement policies. (H)

Second Surgical Opinion

A cost containment technique to help patients and insurance companies determine whether a recommended procedure is necessary, or whether an alternative method of treatment could accomplish the same result. Some health policies require a second surgical opinion before specified procedures will be covered, and many policies pay for the second opinion. (H)

Secondary Care

Medical services provided by physicians who do not have first contact with patients. Examples would be specialists such as urologists, cardiologists, etc. See also Primary Care and Tertiary Care. (H)

Secondary Coverage

Coverage which provides payment for charges not covered by the primary policy or plan. A system to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100 percent of the claim.

Section 125 Plan

A plan which provides flexible benefits. This plan qualifies under the IRS code which allows employee contributions to meet with pre-tax dollars. (H)

Self-Employed Health Insurance

Insurance for the self-employed is often more expensive and more limited, however, similarly to all "small business health insurance", it offers certain tax advantages.

Self-Funded Plan

Plan of insurance where an employer, which has fairly predictable claim costs, pays the claims rather than an insurance company. The services provided by an insurer, such as providing claim forms and processing claims, when the insurer is not the party funding the loss payments. See also Self Funded Plan. (LI,H)

Self-Inflicted Injury

An injury to the body of the insured inflicted by himself. (H)

Service Area

The area, allowed by state agencies or by the certification of authority, in which a health plan can provide services. (H)

Service Benefits

Medical expense benefits provided by service associations whereby benefits are identified in terms of days of coverage instead of monetary values. (H)

Service Plans

Plans of insurance where benefits are the actual services rendered rather than a monetary benefit. Blue Cross plans are nonprofit hospital expense prepayment plans designed primarily to provide benefits for hospitalization coverage, with certain restrictions on the type of accommodations to be used.(H).Blue Shield plans are prepayment plans offered by voluntary nonprofit organizations covering medical and surgical expenses. (H)

Short Term Health Insurance

A type of health insurance plan purchased to cover gaps in coverage, which can occur between jobs, after a move, etc.

Short-Term Disability Income Policy

A disability income policy with benefits payable for "Short Term," usually less than two years, as opposed to a Long Term Disability Income policy. (H)

Short-Term Disability Insurance

A group or individual policy usually written to cover disabilities of 13 or 26 weeks duration, though coverage for as long as two years is not uncommon. Contrast with Long-Term Disability Insurance. (H)

Sickness

Includes physical illness, disease, pregnancy, but does not include mental illness. (H)

Sickness Insurance

A form of Health Insurance against loss by illness or disease. It does not include accidental bodily injury. (H)

Single Carrier Replacement

A situation where one carrier replaces several other carriers who had been providing services. (H)

Skilled Nursing Care

Daily nursing and rehabilitative care that is performed only by or under the supervision of skilled professional or technical personnel. Skilled care includes administering medication, medical diagnosis and minor surgery. (H)

Skilled Nursing Facility (SNF)

A facility designed to qualify for treatment to Medicare eligible people. Included is treatment for rehabilitation and other care such as 24-hour nursing coverage, physical, occupational, and speech therapies, etc. (H)

Small Business Health Insurance

Also known as "small group health insurance", this type of coverage is available to small businesses with between 2 and 50 employees. It often offers less expensive premiums, tax advantages to business owners, and in most cases, coverage cannot be denied.

Small Group Pooling

The combining into one pool of several small group business used especially for computing more accurate premium rates for members of the pool. (H)

SNF

Skilled Nursing Facility. (H)

Social Health Maintenance Organization (SHMO)

A demonstration project funded by the Health and Human Services Department that combines the delivery of acute and long term care with adult day care services and transportation. (H)

Social Security Tax

A tax paid by workers and employers on wages earned. The taxes support the benefit programs under the Social Security System. (H)

Specified Disease Policy

Coverage, usually with a high maximum limit, for all types of medical expenses arising out of diseases named in the contract. Common diseases covered are poliomyelitis, diphtheria, multiple sclerosis, spinal meningitis, and tetanus. Cancer is sometimes covered or may be added with some companies by a rider. (H)

Split Dollar Coverage

An arrangement of Disability Income Insurance in which the employer and employee each pay a portion of the premium. The employer purchases coverage for the sick pay or paid disability leave provided as an employee benefit. The employee pays for disability coverage beyond what the employer provides as a benefit. (H)

Staff Model HMO

This is an HMO where physicians are employed and all premiums are paid to the HMO, which then compensates the physicians on a salary and bonus arrangement. (H)

Standard Class Rate (SCR)

This is rate which is arrived at by using a base rate per participant multiplied by a factor to allow for group demographic information. (H)

Stop-Loss Insurance

This is a type of reinsurance which can be taken out by a health plan or self-funded employer plan. The plan can be written to cover excess losses over a specified amount either on a specific or individual basis, or on a total basis for the plan over a period of time such as one year. (H)

Stop-Loss Provision

The point when the insurance company will begin to pay 100% of accrued medical expenses.

Subscriber

This term has two meanings first, it refers to a person or organization who pays the premiums, and second, the person whose employment makes him or her eligible for membership in the plan. (H)

Subscriber Contract

An agreement which describes the individual's benefits under a health care policy. (H)

Summary Plan Description

This is a recap or summary of the benefits provided under the plan. It is used most often with employees covered by self-funded plans. (H)

Superbill

A form that specifically lists all of the services provided by the physician. It cannot be used in place of the standard AMA form. (H)

Supplemental Medical Insurance (SMI)

Part B of Medicare is a voluntary program which generally covers physician's services and various outpatient services. A premium is charged for electing Part B coverage. (H)

Supplemental Services

Additional services which can be purchased over and above the basic coverage of a health plan. (H)

Surgi-Center

A separate facility (from a hospital) that provides outpatient surgical services. (H)

Surgical Insurance Benefits

A form of Health Insurance against loss due to surgical expenses. (H)

Surgical Schedule

Usually part of a basic medical expense plan which itemizes various surgical procedures and the monetary benefit allocated to each procedure. (H)

Swap Maternity

A provision granting immediate maternity coverage in a Group Health Insurance plan but terminating coverage on pregnancies in progress upon termination of the plan. The term "swap" means providing the coverage at the beginning of the policy where it is not usually provided, but not providing it after the end of the policy where it usually is provided. (H)

Switch Maternity

A provision for Group Health Maternity coverage on female employees only when their husbands are included in the plan as dependents. (H)