SCHEDULE OF BENEFITS AND EXCLUSIONS:
A health insurance listing of the benefits which are covered under the policy guidelines as well as services which are not provided under the policy.
SECOND SURGICAL OPINION:
This is an opinion provided by a second physician, when one physician recommends surgery to an individual. Most health insurance policies cover second surgical opinions.
SELF-INSURED (SELF ADMINISTERED):
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.
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.
SHORT-TERM MEDICAL INSURANCE:
Temporary major medical coverage designed to fill “gaps” in traditional medical coverage. Short-term plans typically last no longer than one year and cannot be renewed.
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 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.
STANDARD INDUSTRIAL CLASSIFICATION (SIC):
Coding of businesses by their product or service. This classification is used in group insurance in determining rates for various industries.
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.
Benefits for a variety of medical conditions that a given state requires of health insurance policies sold in that state.
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.