service benefits

Coverage for defined types of medical care rather than cash (indemnity) benefits.

site of service

Location where care is provided, for example, an inpatient facility or home.

social insurance

Old age, disability, health, or other insurance that is mandated by statute for defined categories of individuals or the entire population, usually financed by payroll and other taxes.

staff model HMO

A health maintenance organization that pays providers through salaried arrangements.

statutory health insurance

Health insurance required or provided automatically by law.

stop-loss insurance

Coverage by an insurer for expenses above a predetermined amount. Specific stop loss defines the expense threshold on an individual basis; aggregate stop loss defines the expense threshold for an entire group.

T

third-party administrator (TPA)

Organization that processes health plan claims without bearing any insurance risk.

third-party payer 

An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services.

triple-option plan

An experience-rated program for an employer group in which a single insurance carrier, Blue Cross and Blue Shield plan, or health maintenance organization provides indemnity or service benefits in conjunction with various managed care or HMO plans.

trust

An arrangement for the care and management of property or funds by a person or third party for the benefit of another.

U

uncompensated care

Health care rendered to persons unable to pay and not covered by private or governmental health insurance plans; includes both unbilled charity care and bad debts (services billed but not paid).

uncontrollable risks

Risks associated with events not thought to be under an individual's control.

underwriting

Determining whether to accept or refuse individuals or groups for insurance coverage (or to adjust coverage or premiums) on the basis of an assessment of the risk they pose and other criteria (e.g., insurer's business objectives).

utilization management

A set of techniques used on behalf of a purchaser of health benefits to manage costs through case-by-case assessments of the clinical justification for proposed medical services (e.g., hospitalization and specific types of surgery).



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