Any health care services, supplies, procedures, therapies or devices that the health plan determines regarding coverage for a particular case to be either (i) not proven by scientific evidence to be effective, or (ii) not accepted by health care professionals as being effective.

The statement sent to a participant in a health plan listing services, amounts paid by the plan, and total amount billed to the patient.

A facility such as a nursing home which is licensed to provide 24 hour nursing care service in accordance with Government laws. Three levels of care may be provided – skilled, intermediate, custodial, or any combination.

A provision in certain tailor made Group Health Policies to allow the insured person to receive benefits for specified losses sustained after the termination of coverage, such a maternity expenses benefit incurred for a pregnancy in progress at the time of the termination.

A facility whose primary purpose is the provision of care for emergency medical conditions. Also, called emergi-center or urgi-center.

A facility which only provides outpatient surgical services. Also called surgi-center.

Under this model the primary care physician (the gatekeeper) is the initial contact for the patient for medical care and for referrals. This is also called a closed access or closed panel.

A drug which is exactly the same as a brand name drug and which is allowed to be produced after the brand name drug’s patent has expired. It is also called a “generic equivalent.”

A form used by underwriters to assist in evaluating groups or individuals to determine whether they are acceptable risks.