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| SCA |
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See Sudden Cardiac Arrest.
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| Schedule (Surgical) |
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A list of specified amounts payable for surgical procedures, Dismemberments, ancillary expenses, and the like in Hospital and medical reimbursement policies.
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| Schedule of Benefits and Exclusions |
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A Health Insurance (HI) listing of the Benefits which are covered under the Policy guidelines as well as services which are not provided under the policy.
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| Second Surgical Opinion |
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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.
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| Secondary Care |
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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.
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| Secondary Coverage |
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Coverage which provides payment for charges not covered by the primary Policy or plan. See also Coordination of Benefits (COB).
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| Section 1115 Waivers |
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Waivers that states could obtain from the federal government which allowed them to set up Managed Care demonstration projects.
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| Section 125 Plan |
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A plan which provides flexible Benefits. This plan qualifies under the IRS code which allows Employee Contributions to meet with pre-tax dollars.
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| Section 1915(B) Waivers |
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Waivers that states could obtain from the federal government that allowed them to restrict a Medicaid Recipient's choice of Providers by using a Primary Care Case Manager (PCCM) or other arrangement.
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| Segments |
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See Market Segments.
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| Self-Funded Plan |
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Plan of insurance where an employer, which has fairly predictable Claim costs, pays the Claims rather than an insurance company. See alsoAdministrative Services Only (ASO).
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| Self-Inflicted Injury |
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An Injury to the body of the Insured inflicted by himself.
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| Self-Insured (Self Administered) |
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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 theEmployee Retirement Income Security Act (ERISA) of 1974. Hence, self-insured Health Plans fall under federal, rather than state, regulation.
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| Self-Insured Plan |
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See Self-Funded Plan.
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| Senior Market |
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A market segment that is comprised largely of persons over age 65 who are eligible forMedicare Benefits.
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| SEP or "Special Election Period" |
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The time period granted to a Medicare Beneficiary who is allowed to change plans outside of the normal AEP. Examples of people who are granted a SEP are: Medicaid Recipients (dual-eligibles), Victims of Hurricane Katrina, or Medicare beneficiaries who are no longer part of a creditable prescription drug plan (such as when their individual plan no longer exists). When someone involuntarily loses their existing Benefits, they have a 60 day SEP during which they are able to enter into another Medicare Part D plan. Also, if someone moves out of the Service Area of their plan (for instance, moving to another state), they will have a 60 day SEP after the move during which they can re-enroll into a Medicare Part D plan. Related to this word are AEP, IEP, and OEP.
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| Service Area |
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The geographic area, as defined by the Insurance Carrier, served by Participating Providers. Contact the Network Manager or the Insurance Carrier to determine the precise geographic area serviced by Participating Providers. The Service Area is subject to change at any time without notice.
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| Service Benefits |
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Medical expense Benefits provided by service associations whereby Benefits are identified in terms of days of Coverage instead of monetary values.
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| Service Plans |
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Plans of insurance where Benefits are the actual services rendered rather than a monetary Benefit. See Blue Cross and Blue Shield.
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| Service Quality |
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An MCO's success in meeting the nonclinical customer service needs and expectations of plan members.
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| Sherman Antitrust Act |
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A federal act which established as national policy the concept of a competitive marketing system by prohibiting companies from attempting to (1) monopolize any part of trade or commerce or (2) engage in contracts, combinations, or conspiracies in restraint of trade. The Act applies to all companies engaged in interstate commerce and to all companies engaged in foreign commerce. See also Antitrust Laws.
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| Short-Term Disability |
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An Injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which Coverage extends) differs among insurance companies and employers. Short-Term Disability Insurance Coverage is designed to protect an individual's full or partial wages during a time of Injury or illness (that is not work-related) that would prohibit the individual from working.
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| Short-Term Disability Income Policy |
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A disability income Policy with Benefits payable for "Short Term," usually less than two years, as opposed to a Long Term Disability Income policy.
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| Short-Term Disability Insurance |
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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.
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| Short-Term Medical Insurance |
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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.
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| Sickness |
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A disease or illness of a Covered Person. Sickness does not include a family history of a disease or illness or a genetic predisposition for the development of a future disease or illness. BISYS defines Sickness as Includes physical illness, disease, pregnancy, but does not include mental illness.
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| Sickness Insurance |
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A form of Health Insurance (HI) against loss by illness or disease. It does not include accidental bodily Injury.
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| Single Carrier Replacement |
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A situation where one Carrier replaces several other Carriers who had been providing services.
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| Single Plan |
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A plan of insurance covering only the Certificate Holder.
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| Skilled Nursing Care |
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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.
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| Skilled Nursing Facility |
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A facility that provides Inpatient Skilled Nursing Care, rehabilitation services or other related Health Services. "Skilled nursing" does not include a convalescent home or Custodial Care. Also see Medical Facility - Skilled Nursing Facility.
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| Small Group |
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Although each MCO's size limit may vary, generally a Group composed of 2 to 99 Members for which health Coverage is provided by the group sponsor.
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| Small Group Pooling |
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The combining into one pool of several Small Group business used especially for computing more accurate Premium rates for members of the pool.
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| SNF |
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See Skilled Nursing Facility.
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| Social Health Maintenance Organization (SHMO) |
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A demonstration project funded by the Health and Human Services Department that combines the delivery of acute and Long Term Care (LTC) with adult day care services and transportation.
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| Social Security Tax |
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A tax paid by workers and employers on wages earned. The taxes support the Benefit programs under the Social Security System.
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| Special Benefit Networks |
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Provider Networks for particular services, such as mental health, Substance Abuse, or Prescription Drugs
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| Special Exception Rider |
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A form that is included with the plan which identifies a body part, system, disease, Sickness, Injury or other condition for a Covered Person in which all charges related to that body part, system, disease, Sickness, Injury or other condition are excluded from Coverage for a specific period of time as shown in the Special Exception Rider.
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| Specialty Health Maintenance Organization (Specialty HMO) |
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An organization that uses an HMO model to provide healthcare services in a subset or single specialty of medical care.
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| Specialty HMO |
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See Specialty Health Maintenance Organization (Specialty HMO).
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| Specialty Services |
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Services that are provided by independent, specialty organizations rather than by the MCO providing the basic Health Plan.
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| Specific Stop-Loss Coverage |
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See Individual Stop-Loss Coverage.
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| Specified Disease Policy |
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See Dread (or Specified) Disease Policy.
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| Speech Therapy |
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The treatment of a Sickness or an Injury, by a Health Care Practitioner who is a speech therapist, using rehabilitative techniques to improve function for voice, speech, language and swallowing disorders.
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| Split Dollar Coverage |
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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.
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| Staff Model |
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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 Associations (IPA) (IPA)" HMO, in which independent physicians contract with the HMO.
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| Staff Model HMO |
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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.
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| Standard Class Rate (SCR) |
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This is rate which is arrived at by using a base rate per Participant multiplied by a factor to allow for Group demographic information.
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| Standard Community Rating |
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A type of Community Rating in which an MCO considers only community-wide data and establishes the same financial performance goals for all risk classes. Also known as Pure Community Rating.
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| Standard Industrial Classification (SIC) |
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Coding of businesses by their product or service. This classification is used in Group insurance in determining rates for various industries.
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| Standard Of Care |
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A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.
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| Stark Laws |
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See Ethics In Patient Referrals Act.
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| State Insurance Department |
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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
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| State Pharmaceutical Assistance Programs (SPAP) |
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State pharmaceutical assistance programs help cover the Prescription Drug costs of elderly people with low incomes or people with disabilities who don't qualify forMedicaid. Currently, 39 states offer some type of program to provide Prescription Drug Coverage or assistance. Most programs use state funds to subsidize a portion of the costs for people who qualify.
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| State-Mandated Benefits |
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Benefits for a variety of medical conditions that a given state requires of Health Insurance (HI) policies sold in that state
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| Statutory Solvency |
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An insurer's ability to maintain at least the minimum amount of capital and Surplus specified by state insurance regulators.
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| Step Therapy (step edits) |
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In some cases, you're required to first try certain drugs to treat your medical condition before the plan will cover another drug for that condition. You and your doctor must work with the plan to ensure Coverage. These drugs are designated 'ST' in the Formulary.
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| Stop-Loss |
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The dollar amount of Claims filed for Eligible Expenses at which which point you've paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%. Stop-Loss is reached when an insured individual has paid the Deductible and reached the Out-of-pocket maximum amount of Coinsurance.
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| Stop-Loss Insurance |
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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.
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| Stop-loss Provisions |
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A limit in a Health Insurance (HI) Policy that provides for 100% payment of expenses after total patient out-of-pocket expenses exceed a certain contractual dollar amount
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| Structural Integration |
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The unification of previously separate Providers under common ownership or control.
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| Structure Measures |
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Healthcare Quality indicators related to the nature and Quality of the resources that a Managed Care Organization (MCO) has available for patient care.
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| Subacute Medical Care |
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A short-term comprehensive Inpatient program of care for a Covered Person who has a Sickness or an Injury that:
1. Does not require the CoveredPerson to have a prior admission as an Inpatient in a licensed medical facility; and
2. Does not require intensive diagnostic and/or invasive procedures; and
Requires Health Care Practitioner direction, intensive nursing care, significant use of ancillaries, and an outcome-focused, interdisciplinary approach using a professional medical team to deliver complex clinical interventions.
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| Subacute Rehabilitation Facility |
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See Medical Facility - Subacute Rehabilitation Facility.
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| Subauthorization |
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The authorization of one healthcare service concurrently with the authorization of another service. For example, an authorization for hospitalization may cover surgery, anesthesia, pathology, and radiology performed during the hospitalization.
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| Subjective Pain |
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means an alleged pain for which there is no detectable cause and is not supported by medical findings, physiological abnormality, trauma or Injury, disease, or viral invasion as a cause thereof.
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| Subscriber |
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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.
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| Subscriber Contract |
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An agreement which describes the individual's Benefits under a health care Policy.
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| Subsidiary |
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A company that is owned by another company, its parent.
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| Substance Abuse |
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Abuse of, addiction to, or dependence on drugs, chemicals or alcohol as defined in the edition of the International Classification of Diseases (ICD) that is published at the time a Claim is received by the Insurance Carrier.
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| Substantial Duties |
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means the duties that consume most of Your work time as described on Your application for this insurance.
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| Sudden Cardiac Arrest |
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means a Sudden Cardiac Arrest leading to death within seventy two (72) hours of the incident.
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| Summary Plan Description |
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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.
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| Superbill |
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A form that specifically lists all of the services provided by the physician. It cannot be used in place of the standard AMA form.
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| Supplemental Medical Insurance (SMI) |
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Medicare Part B is a voluntary program which generally covers physician's services and various Outpatient Services. A Premium is charged for electing Medicare Part B Coverage.
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| Supplemental Services |
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Additional services which can be purchased over and above the basic Coverage of a Health Plan.
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| Surgical Assistant |
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A Health Care Practitioner who is licensed to assist at surgery in the state and credentialed at the facility where the procedure is performed but who is not qualified by licensure, training and Credentialing to perform the procedure as a primary surgeon at that facility
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| Surgical Insurance Benefits |
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A form of Health Insurance (HI) against loss due to surgical expenses.
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| Surgical Schedule |
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Usually part of a basic medical expense plan which itemizes various surgical procedures and the monetary Benefit allocated to each procedure. Also see Schedule
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| Surgi-Center |
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A separate facility (from a hospital) that provides Outpatient surgical services.
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| Surplus |
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The amount that remains when an insurer subtracts its liabilities and capital from its assets.
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| Swap Maternity |
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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.
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| Switch Maternity |
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A provision for Group Health Maternity Coverage on female employees only when their husbands are included in the plan as Dependents.
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