Glossary

A contract, such as an insurance policy, or other financial arrangement providing medical, prescription drug, dental, vision, disability income, long-term care, or other health-related benefits, whether on a reimbursement, indemnity, or service benefit basis, regardless of the form of the risk-bearing entity.

A clause in a residency agreement guaranteeing access to health care and defining the type of health care services to be provided to the resident. These health care services may be offered with or without additional charges to the periodic fees.

A facility associated with a CCRC where health care is provided to residents in accordance with a residency agreement. The health center typically includes some combination of assisted living, special care, and nursing care units. Non-residents may also live in the health center.

A required regulatory filing for health benefits, accident and health insurance, and entities providing health benefits, which requires projection of future contingent events, for rates or benefits, or financial projections. Rate or benefit filings include, but are not limited to, the following: a. filings of manual rates, rating factors, or underwriting manuals; b.filings of rating methodology, such as experience rating formulas and factors; c.statements of actuarial soundness or rate adequacy, as may be defined by the regulatory body, for future rating periods; d. certification of benefit values, such as actuarial value or actuarial equivalence, for example, as required by the Affordable Care Act; and e.other filings of a similar nature as may be required by a regulatory body. (ASOP No. 8)

Coverage associated with contract provisions for medical, dental, vision care, disability income, accidental death and dismemberment, long-term care, and similar benefits, on either a reimbursement or service-benefit basis, sold by insurance companies, health maintenance organizations, hospital and medical service organizations, and other entities subject to insurance regulatory authorities. (ASOP No. 11)

An asset that is estimated using actuarial considerations or any other asset included in the health benefit plan statement of actuarial opinion. Examples include risk adjustment transfer payment receivables, pharmacy rebate receivables, provider settlement receivables, and Medicare Part D settlement receivables.

An amount recorded in financial statements or accounting systems in order to reflect health benefit plan obligations. Common examples include health claims in course of settlement, health claims that are incurred but not yet reported, liabilities for settlements of provider contracts, contract reserves, experience refund liabilities, premium deficiency reserves, premium stabilization reserves, and liabilities for reinsurance payable.

A contract or other financial arrangement providing hospital, medical, prescription drug, dental, or vision benefits. (Determining Minimum Value and Actuarial Value Under the Affordable Care Act)

An insurance company, health maintenance organization, hospital or medical service organization, self-insured health benefit plan sponsor, governmental health benefit plan sponsor, or any other health benefit plan sponsor from which health filings are required. (ASOP No. 8)

Using healthcare claims, pharmacy claims, lab test results, health risk appraisal or other data based on underlying conditions or treatment as well as demographic information such as age and gender. (ASOP No. 45)

A/E analysis using the mortality tables, underwriting multipliers, improvement factors, medical records and other pertinent information actually used when the life expectancy was issued. (Exposure Draft, Proposed ASOP Life Settlements Mortality)

Mortality assumptions developed from a base  mortality table using information such as underwriting multipliers, improvement factors, medical records and other pertinent information relevant to the individual life expectancies as of their associated underwriting dates. (ASOP No. 48)

The contribution a particular policy or class of similar eligible policies has made to the company’s statutory surplus and asset valuation reserve in a given year. (ASOP No. 37)

A subset of data that is withheld intentionally when developing a predictive model so that the model may be validated later with data that were not used to develop the model.

Care received at the patient’s home, such as part-time skilled nursing care, custodial care, speech therapy, physical or occupational therapy, part-time services of home health aides, or help from homemakers or chore workers.

The degree to which the expected outcomes within a risk class have comparable value. (ASOP No. 12)

A program that provides health care to a terminally ill person and counseling for that person and his or her family. Hospice care can be offered in a hospice setting established for this single purpose, a nursing home, or in the person’s home, where nurses and social workers can visit the patient regularly. (ASOP No. 18)