Maximum level of spending for the health sector or certain categories of services. It is usually established by the government through rate setting or premium limits.

Statistical examination of insurance experience for any part of the group business such as a line or a territory; any group of cases, coverages, or benefits; or any single case, coverage, or benefit. The study may include single or multiple experience periods, past and future trends, and various descriptive statistics.

Time period of usually 12 months in which premium and insurance claim records are gathered for a rate review. Also referred to as a review period .

Insurance premium based on the experience rating. This is periodically adjusted in line with actual insurance claims or utilization experience.

Insurance premium rates for group insurance coverage based, wholly or partially, on the past claims of the group.

Any treatment, procedure, equipment, drug, drug usage, device, or supply not generally accepted as standard care in the practice of medicine. This includes services or supplies requiring federal or government approval not granted at the time services were rendered. Also called investigative . See experimental care .

1. Medical care that has not yet been accepted as standard care in the practice of medicine. 2. Any medical care that needs federal or other governmental agency approval that was not given at the time the care was provided. Also called investigative care .

Medical services, supplies, treatments, or drug therapies still in a trial stage, determined by the insurance plan not to be generally accepted as standard care in the practice of medicine, and not effective in treating the illness for which their use is intended. Also called unproved procedures .