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Terms We Use
Note: The following terms are not necessarily the legal definitions that appear
in the HIPAA statute or regulations. For definitions of specific terms, please
refer to the pertinent statute or regulation.
[A - D]
[E - H]
[I - M]
[N - R]
[S - Z]
- Affiliation Period
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If your group health plan provides coverage through a contract with an HMO, an
affiliation period is the length of time an HMO may make you wait before you can receive
benefits. During this time, you cannot be charged a premium. Under HIPAA, an affiliation
period may not last longer than two months (three months if you are a late enrollee), and
it must begin on your enrollment date under the group health plan. As a result, if you
switch to HMO coverage more than 3 months after your enrollment date, the HMO cannot impose
an affiliation period on you. Affiliation periods are an alternative to pre-existing
condition exclusions; an HMO cannot impose both, even on different individuals.
- Certificate of Creditable Coverage
- A certificate of creditable coverage is a document that describes how much creditable
coverage you have, and the date the coverage ended. Most group health plans and insurance
issuers are required to issue certificates automatically shortly after your coverage ends.
You also can request a certificate describing particular coverage at any time while the
coverage is in effect and within 24 months of the time the coverage ends.
- Church Plan
- A church plan is a health plan that is established by a church or other religious
organization, or by a convention or association of churches, for its employees. Church
plans may include employees of hospitals or universities owned and operated by such
religious organizations.
- COBRA Continuation Coverage or COBRA
- COBRA continuation coverage is coverage that is offered to you in order to
satisfy the requirements of the Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA). COBRA requires employers to permit employees or family members to
continue their group health coverage at their own expense, but at group rates, if
they lose coverage because of a loss of employment, reduction in hours, divorce,
death of the supporting spouse, or other designated events.
- Conversion Coverage
- Conversion coverage is individual health coverage that might be offered to you
when you lose group health plan coverage.
- Conversion Policy
- A conversion policy is an individual health insurance policy that you may be able
to get after losing group coverage. A health insurance issuer may allow you to
"convert" to an individual policy once you have lost group coverage. This means you
would still have a policy generally with the same issuer, but it will be an individual
policy. The benefits offered by the conversion policy may not be the same as those under
your group policy. Generally, the premiums for a conversion policy will be more expensive.
- Creditable Coverage
- Creditable coverage is prior health care coverage that is taken into account
to determine the allowable length of pre-existing condition exclusion periods
(for individuals entering group health plan coverage) or to determine whether
an individual is a HIPAA eligible individual (when the individual is seeking
individual health insurance coverage.) Most health coverage is creditable
coverage, including coverage under any of the following:
- a group health plan (related to employment).
- a health insurance policy; including short-term limited duration policies.
- Medicare Part A or Part B;
- Medicaid;
- a medical program of the Indian Health Service or tribal organization;
- a State health benefits risk pool;
- TRICARE (the health care program for military dependents and retirees);
- Federal Employees Health Benefit Plan;
- a public health plan; or
- a health plan under the Peace Corps Act.
- Enrollment Date
- Your enrollment date is the first day on which you are able to receive benefits
under a group health plan, or if the plan imposes a waiting period, the first day of
your waiting period. Unless you chose not to participate in the plan when you first
are hired, your enrollment date usually is the date on which you begin work.
- ERISA
- The Employee Retirement Income Security Act (ERISA) is a law that provides
protections for individuals enrolled in pension, health, and other benefit plans
sponsored by private-sector employers. The US Department of Labor administers ERISA.
- Genetic Information
- This term refers to information about genes, gene products, and inherited
characteristics that may derive from the individual or a family member.
- Group Health Plan
- A group health plan is an employee welfare benefit plan maintained by an employer
or union that provides medical care to employees and often to their dependents as well.
- Health Insurance Issuer or Issuer
- Any company that sells health insurance is a health insurance issuer.
Insurance companies and HMOs are both health insurance issuers.
- High-Risk Pool
- A high-risk pool is any arrangement established and maintained by a State
primarily to provide health insurance benefits to certain State residents who,
because of their poor health history, are unable to purchase coverage in the
open market or can only acquire such coverage at a rate that is substantially
above the rate offered by the high-risk pool. Coverage offered by a high-risk
pool is comparable to coverage available in the open market, but the risk for
that coverage is borne by the State, which generally supports the losses
sustained by the pool through assessments on all health insurers doing business
in the State, based on their relative market shares, and/or through general tax revenues.
- HIPAA Eligible Individual
- A HIPAA eligible individual means a person who is guaranteed the right under
HIPAA to purchase individual health insurance coverage with no pre-existing condition
exclusions. If you meet all the following requirements, you are an "eligible individual"
and HIPAA guarantees your right to purchase individual coverage:
- You don't have, or will be losing, coverage under a group health plan or an
individual health insurance policy.
- You have at least 18 months of creditable coverage without any significant break.
(A significant break is a period of 63 or more days during all of which you had no
coverage. If you get coverage by midnight of the 63rd day, you have not incurred
a significant break in coverage).
- Your most recent coverage must have been a group health plan (through your or a
family member's employer or union).
- You are not eligible for Medicare or Medicaid.
- You do not have other health insurance.
- You did not lose your insurance for not paying the premiums or for committing fraud.
- You accepted and exhausted your COBRA continuation coverage or similar State coverage
if it was offered to you.
- Individual Market
- This refers to health insurance that is made available to individuals and their
dependents other than in connection with a group health plan.
- Insured Plan
- An insured plan is a group health plan under which the benefits are provided
by the sponsoring employer or union through the purchase of health insurance coverage
from an HMO or an insurance company. In exchange for a premium or contribution paid
by the employer or union and/or its employees or members, the HMO or the insurance
company bears full risk for the cost of the benefits provided.
- Large Employer
- A large employer has at
least 51 employees.
- Late Enrollee
- A late enrollee is an individual who does not enroll in a group health plan at
the first opportunity, but enrolls later if the plan has a general open
enrollment period. A late enrollee is different from a special enrollee.
- Medical Condition
- A medical condition is any physical or mental condition resulting from an
illness, injury, pregnancy, or congenital malformation.
- Network Plan
- A network plan is a health
insurance policy that provides coverage through a
defined set of providers under contract with the
insurance issuer.
- Plan Administrator
- The person responsible for answering any questions you may have about your
group health plan. The materials that describe the plan should identify who your
plan administrator is.
- Policy
- An insurance policy or any other contract (such as an HMO contract) that provides
you or your group health plan with health insurance coverage.
- Pre-existing Condition Exclusion
- A pre-existing condition exclusion limits or denies benefits for a medical
condition that existed before the date that coverage began. A "medical condition"
is any physical or mental condition resulting from an illness, injury, pregnancy,
or congenital malformation. HIPAA limits the use of pre-existing condition exclusions
and establishes requirements that a pre-existing condition exclusion must satisfy.
- Premiums
- Premiums refer to the amount that you contract to pay an insurance issuer or HMO,
generally on a periodic basis, in return for health coverage.
- Self-Insured(or Self-Funded)Plan
- A self-insured (or self-funded) plan is a group health plan under which the risk
for the cost of the benefits provided is borne by the sponsoring employer or union. The
employer or union may hire a third party administrator to perform such services as paying
claims, collecting premiums, or supplying other administrative services), but the financial
liability for the cost of the benefits provided remains with the employer or union.
Typically, a self-insured plan will purchase stop-loss insurance to limit its financial
liability to a certain level.
- Short-Term Limited Duration Insurance
- Short-term limited duration
insurance is a health insurance contract that
expires within 12 months and cannot be renewed beyond that point.
- Signifigant Break in Coverage
- A significant break in
coverage is 63 or more full days in a row without
any creditable coverage. Some States, however, may allow
a longer break in coverage.
- Small Employer
- A small employer has at
least two but not more than 50 employees. Some
States, however, may consider a business with only
one employee a small employer.
- Special Enrollment
- A special enrollment is an opportunity to enroll in a group health plan without
having to wait for an open enrollment period. A group health plan must provide you with
an opportunity for special enrollment if you declined coverage under the plan because you
had alternative coverage but since have lost that alternative coverage, or if you have new
dependents (through marriage, birth or adoption).
- Waiting Period
- In the individual market, a
waiting period is the time between when your
application is filed and your coverage begins. With
respect to a group health plan, it is the time that
must pass before a new employee becomes eligible for
benefits under the plan. The waiting period
generally starts on the date of hire.
Last Modified on Friday, September 17, 2004
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