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| Base Beneficiary Premium |
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The Base Beneficiary Premium is the Premium amount set by theCenters for Medicare and Medicaid Services (CMS) annually as being the average Premium available from PDP plans nationally. This amount may be more or less than the Premium amount set for the PDP plan you select.
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| Base Capitation |
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The total amount which covers the cost of health care per person, minus any mental health or Substance Abuse services, pharmacy, and administrative charges.
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| Basic Hospital Expense Insurance |
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Hospital Coverage providing Benefits for room and board and miscellaneous Hospital expenses for a specified number of days during Hospital confinement.
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| Bed Days/1,000 |
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The number of Inpatient Hospital days per 1,000 Members of the Health Plan.
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| Behavioral Health |
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Any conditional classified as a Mental or Nervous Disorders in the edition of the International Classification of Diseases (ICD) that is published at the time a Claim is received by the Insurance Carrier. Behavioral Health also includes family and Marriage Counseling.
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| Behavioral Health Facility or Program - Partial Hospital and Day Treatment. |
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A program that provides care for Behavioral Health or Substance Abuse on an Outpatient basis. Room and board and overnight services are not covered. This type of program must meet all of the following requirements:
a. Be licensed by the state in which the services are rendered and Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Medicare to provide care for Behavioral Health or Substance Abuse.
b. Provide at least 3 hours of individual or group psychotherapy by an appropriately licensed Health Care Practitioner 1 to 5 days per week.. Recreational therapy, educational therapy, music and dance therapy and similar services may be provided but are not included in the 3 hour minimum requirement of psychotherapy.
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| Behavioral Health Inpatient Facility - Acute |
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A facility that provides acute care or Subacute Medical Care for Behavioral Health or Substance Abuse on an Inpatient basis. This type of facility must meet all of the following requirements:
a. Be licensed by the state in which the services are rendered and Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Medicare to provide acute care or Subacute Medical Care for Behavioral Health or Substance Abuse.
b. Be staffed by an on duty licensed physician 24 hours per day.
c. Provide nursing services supervised by an on duty Registered Nurse (RN) 24 hours per day.
d. Maintain daily medical records that document all services provided for each patient.
e. Provide a restrictive environment for patients who present a danger to self or others.
f. Provide alcohol and chemical dependency detoxification services.
g. Handle medical complications that may result from a Behavioral Health or Substance Abuse diagnosis.
h. Not primarily provide Rehabilitation Services, residential, partial hospitalization or intensive Outpatient services although these services may be provided in a distinct section of the same physical facility.
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| Behavioral Health Program - Outpatient, Intensive |
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A program that provides care for Behavioral Health or Substance Abuse on an Outpatient basis. Room and board and overnight services are not covered. This type of program must meet all of the following requirements:
a. Be licensed by the state in which the services are rendered and Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Medicare to provide care for Behavioral Health or Substance Abuse.
b. Provide at least 6 hours of therapeutic intervention per week. Therapeutic intervention consists of at least 2 hours per week of individual or group psychotherapy by an appropriately licensed Health Care Practitioner. Chemical dependency support, medication, education and similar services may be provided but are not included in the two hour minimum requirement of psychotherapy.
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| Behavioral Health Rehabilitation and Residential Facility |
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A facility that provides care for Behavioral Health or Substance Abuse on an Inpatient basis. This type of facility may also be referred to as a residential facility and must meet all of the following requirements:
a. Be licensed by the state in which the services are rendered and Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Medicare to provide residential care for Behavioral Health or residential/rehabilitation care for Substance Abuse.
b. Be staffed by an on duty licensed physician 24 hours per day.
c. Provide nursing services supervised by an on duty Registered Nurse (RN) 24 hours per day.
d. Provide an initial evaluation by a physician upon admission and ongoing evaluations for patients on a regular basis.
e. Provide a restrictive environment for patients who present a danger to self or others.
f. Provide at least 3 hours per day of individual or group psychotherapy by an appropriately licensed Health Care Practitioner 6 days per week. Recreational therapy, educational therapy, music and dance therapy and similar services may be provided but are not included in the 3 hour minimum per day requirements of psychotherapy.
g. be able to handle medical complications that may result from Substance Abuse diagnosis.
h. Not primarily provide partial hospitalization or intensive Outpatient services although these services may be provided in a distinct section of the same physical facility.
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| Behavioral Healthcare |
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The provision of mental health and Substance Abuse services.
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| Beneficence |
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An ethical principle which, when applied to Managed Care, states that each Member should be treated in a manner that respects his or her own goals and values and that Managed Care Organization (MCO)s and their Providers have a duty to promote the good of the Members as a group.
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| Beneficiary |
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A person eligible for Benefit under a Health Insurance (HI) Policy.
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| Beneficiary - AD&D |
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In an AD&D Policy this means the person(s) or entity named on the schedule page. If noBeneficiaryis named, then the Insured's estate will be recognized as the Beneficiary. If more than one person or entity is named and not specified as to a percentage or specific Benefit amount for that person or entity, then the Benefit will be divided equally amongst those named. All death Benefits will be paid to the Beneficiary.
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| Benefit |
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Amount payable by the insurance company to a Claimant, assignee, or Beneficiary when the Insured suffers a loss. The plan benefits are itemized in the Schedule of Benefits and Exclusions, also known as Schedule or Benefit Summary.
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| Benefit Cap |
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Total dollar amount that a payer will reimburse for covered health care services during a specified period, such as one year.
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| Benefit Design |
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The process an MCO uses to determine which Benefits or the level of Benefits that will be offered to its Members, the degree to which Members will be expected to share the costs of such Benefits, and how a Member can Access medical care through the Health Plan.
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| Benefit Levels |
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The maximum amount a person is entitled to receive for a particular service or services as spelled out in the contract with a Health Plan or insurer.
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| Benefit Package |
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A description of what services the insurer or Health Plan offers to those covered under the terms of a Health Insurance (HI) contract.
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| Benefit Percentage |
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Percentage of Covered Expenses the plan pays after the Deductible.
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| Benefit Period |
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A Benefit Period begins the first day you stay in a Hospital or Skilled Nursing Facility and ends when you have been out of the Hospital or Skilled Nursing Facility for 60 days in a row. If you go into the facility after one Benefit Period has ended, a new Benefit Period begins. There is no limit to the number of Benefit Periods you can have.
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| Benefit Waiting Period |
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The period of consecutive days or months that must pass after the Effective Date of Coverage before a Covered Person is eligible to be covered for specific benefits as shown in the Benefit Summary under the terms of this plan. Each Covered Person is responsible for payment of all services that are received during the benefit Waiting Period. The Benefit Waiting Period applies separately to each Covered Person.
A Benefit Waiting Period only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what any applicable Benefit Waiting Periods are along with the Covered Charges to which they apply.
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| Billed Claims |
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The amounts submitted by a Health Care Provider for services provided to a covered individual.
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| Binding Receipt |
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See Conditional Binding Receipt.
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| Birthday Rule |
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One method of determining which parent's medical Coverage will be primary for Dependent children: the parent whose birthday falls earliest in the year will be considered as having the primary plan.
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| Blanket Insurance |
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A contract of Health Insurance (HI) that covers all of a class of persons not individually identified in the contract.
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| Blanket Medical Expense |
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A Policy or provision in a Health Insurance (HI) contract that pays all medical costs, including hospitalization, drugs, and treatments, without limitation on any item except possibly for a maximum aggregate Benefit under the policy. It is often written with an initial Deductible amount.
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| Blended Rating |
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For groups with limited recorded Claim Experience, a method of forecasting a group's cost of Benefits based partly on an MCO's Manual Rates and partly on the group's Experience.
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| Blue Cross |
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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.
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| Blue Plan |
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A generic designation for those companies, usually writing a service rather than a reimbursement contract, who are authorized to use the designation Blue Cross or Blue Shield and the insignia of either.
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| Blue Shield |
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Blue Shield plans are prepayment plans offered by voluntary nonprofit organizations covering medical and surgical expenses.
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| Board Certified |
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A physician or other professional who has passed an Examination which certifies him or her as a specialist in a particular medical area.
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| Board Eligible |
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A professional person or physician who is eligible to take a specialty Examination.
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| Bonus Drug List |
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An additional list of commonly used Prescription Drugs that are not covered by Medicare Part D like Alphrazolam, Lorazepam, and Temazepam, but are included in the UnitedHealth RX plans.
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| Brand |
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A name, number, term, sign, symbol, design, or combination of these elements that an organization uses to identify one or more products.
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| Brand Name Drugs |
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Pharmaceutical companies hold patents on the drugs that they develop for a certain amount of time, these drugs are sold under a trademarked Brand name.
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| Broker |
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A licensed legal representative of the Policyholder, who negotiates with an insurance company on behalf of a customer, but is paid a commission by the insurance company. This salesperson who has obtained a state license to sell and service contracts of multiple Health Plans or insurers, and who is ordinarily considered to be an agent of the buyer, not the Health Plan or insurer.
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| Business Integration |
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The unification of one or more separate business (nonclinical) functions into a single function.
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| Business Overhead Expense |
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A disability income Policy which indemnifies the business for certain overhead expenses incurred when the business owner is Totally Disabled.
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