The review that determines whether provided or proposed health care services are or were medically necessary. This does not apply to emergency services but involves "before, during and after" medical services.

A review of claims for services already received. This review may be used to confirm medical necessity of services, identify coordination of benefits opportunities, and to determine if a non-pre-certification penalty applies.

This Act states employers with 20 or more employees must provide a health coverage continuation option to all covered employees and dependents up to 18 months in the event of:

Termination of employee (unless it is for cause as defined by federal law)

Reduction of hours for employee, so they no longer qualify as a full-time employee

Coverage may continue up to 29 months if an employee or dependent is totally disabled at the time of a qualifying event

These were developed by the NAIC and must, by law, be included in every individual accident and health insurance policy. Different wording may be used as long as it is at least as favorable as the original wording. No additional provisions may be included which otherwise restrict or modify a uniform provision. There are 12 of these that are designed to protect the insured's interests.

A utilization review conducted prior to the delivery of the requested medical service. They include the initial review conducted before treatment starts, and the initial review for treatment to a different body part. During this review, copies of medical records may be required only when necessary to verify that the health care services being considered are medically necessary.

Covers a group of individuals whose membership changes frequently, such as students, passengers traveling on a common carrier, sports teams, volunteer firefighters, or other groups of people while being exposed to a specific risk. Blanket policies do not name specific individuals as insureds, the insured organization/business must certify a covered person's claim as legitimate. The term for a policy cannot exceed one year.

Under this an employer always must maintain the employee's existing level of health coverage (including family or dependent coverage) under a group health plan during the period of this leave, provided the employee pays his or her share of the premiums.

The Taft-Hartley Act was a 1947 amendment to the National Labor Relations Act of 1937. Among the provisions of the Act, these were permitted, under certain conditions, to establish primarily employer-funded trusts for the provision of health and welfare benefits to union members.

A utilization review conducted while services are being provided. The insurer monitors the insured's hospital stay to make certain that everything is proceeding according to schedule. The length of hospital stay is monitored.

The time after the premium due date before the policy lapses for nonpayment of premium. Must not be less than 7 days (weekly premiums), 10 days (monthly premiums) and 31 days for all other modes of premium.

This was designed to provide protections for persons with preexisting conditions who left one employer and might not be covered by a new group health plan. In addition, this created a number of regulations concerning privacy protections for personal health information, including safeguards for recordkeeping and sharing of medical records.

Entities formed by unrelated businesses in the same or related industrial classification and/or third-party administrators who are called sponsors, thus allowing small to medium sized employers with limited numbers of employees to combine their employees into a single, larger group in order to obtain more favorable life and health insurance premiums and increased benefits (can also provide access to other employee benefit plans, such as defined contribution or defined benefit retirement plans).

Requires the insured to notify his/her insurer in advance of certain non-emergency procedures. The physician may submit claim information prior to treatment to know in advance if the procedure is covered and at what rate benefits will be paid.

Generally formed by larger employers for the purpose of obtaining more favorable rates for life and health insurance. These groups can be created as fully insured, self-funded or partially self-funded benefit programs as an alternative mechanism to traditional health insurance for small employers. In order for the Department of Insurance to grant a Certificate of Compliance, the group must adhere to standards set forth in the code that are consistent with the provisions of ERISA.

Guaranteed renewable and the premiums cannot be altered. This is most favorable for the insured because only the owner can terminate the policy and rates never increase. The insurer cannot change the policy terms or provisions, except to make them more favorable for the insured, once issued.

Managed care plans are known for stressing this type of care. This is care designed to prevent illness or disease. The basic premise is that it is more cost effective to prevent losses than to treat losses after they occur. Examples include covering well child care visits, immunizations, mammography screenings, as well as nutrition and weight loss programs.

This allows the insured, at the insurer's discretion, to put back in force a policy that has lapsed for nonpayment of premium by paying past due premiums plus interest. A reinstatement application to prove insurability may also be required. If the insurer does not reject the reinstatement application within 45 days, coverage will be automatically reinstated. Accidents are covered immediately and sickness coverage begins 10 days after reinstatement.

A specified period of time before coverage goes into effect for preexisting conditions. This is designed to protect the insurer for losses due to a sickness that occur immediately (10-30 days)after the policy is issued. Losses due to an accident are not preexisting and are covered immediately with no waiting period.

The law provides numerous rights and protections that make health coverage more fair and easy to understand, along with subsidies (through “premium tax credits” and “cost-sharing reductions”) to make it more affordable.