GLOSSARY

Captitation:  A rate paid, usually monthly, to a health care provider. In return, the provider agrees to deliver the health services agreed upon to any covered person.

Claims Basis:  The allowable period of time in which the allowable claims can incur and the allowable period of time in which claims can be reported and paid.

Coinsurance:  The percentage applied to the eligible claim amount prior to reimbursement.  The percentage is applied after the deductible has been met.

Deductible: The amount subtracted from the eligible claim amount prior to reimbursement from the insurance carrier.  The deductible is applied after the maximum allowable schedule is applied to the eligible services.

Effective Date: The first day that stop-loss coverage is in place and effective.

Eligible Services: The services covered under the stop-loss coverage.

Errors and Omissions:  What is What Is Errors And Omissions (E&O) Insurance?

Errors and Omissions Insurance is business liability insurance for professionals such as insurance agents, real estate agents and brokers, architects, third party administrators and other business professionals. An error or omission, a mistake, which causes financial harm to another, can occur on almost any transaction in any profession. This type of insurance helps to protect a professional, an individual or a company, from bearing the full cost of defense for lawsuits relating to an error or omission in providing covered Professional Services. This is a separate coverage from a standard general liability or property insurance policy.

Experience Refund:  The amount that may be returned to the Insured for favorable claims experience.

In-Network (Contracted):  Services provided by providers within the Insured’s network or by any other provider which has a contract with the Insured.

Insurance Carrier: The insurance company which is providing the coverage for the stop-loss coverage.

Maximum Allowable: The highest possible amount allowed for a service or procedure, subject to reasonable and customary and the amount actually paid.

Maximum Benefit: The highest possible amount that the insurance carrier will pay for a member during a contract year and/or lifetime and/or for all members for the policy period.

Out-of-Network (Non-Contracted): Services provided by providers outside the Insured’s network or who do not have a contract with the Insured.

Per Diem: The allowable charge per day for any hospital service.

Reinsurance: Insurance that is purchased by an insurance company from another insurance company as a means of managing risk. 

Value-Added Services: Additional services or programs offered to the Insured.  There may be a charge by the insurance carrier for some of the services provided.