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Common Insurance Terms

Contracted insurance - Insurance carriers with which University of Missouri Health Care and University Physicians have negotiated contracts to provide patient care at reduced rates.

Managed care insurance - A medical delivery system that attempts to manage the quality and cost of medical services which individuals receive . Most managed care systems offer HMO (health maintenance organization) and PPO (preferred provider organization) plans that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality by emphasizing prevention of disease.

Non-contracted insurance - Insurance carriers with which University of Missouri Health Care and University Physicians are not contracted. MUHC and University Physicians are not obligated to take any adjustments applied on the explanation of benefits, and additional out-of-pocket expenses may apply.

Primary insurance - An insurance policy, plan or program that pays first on a claim for medical services. The order of insurance hierarchy is decided by the Missouri Department of Insurance, Financial Institutions and Professional Registration.

Secondary insurance - An insurance policy, plan or program that pays second on a claim for medical care. This could be Medicare, Medicaid or another insurance payer depending on the situation.

Missouri MO HealthNet (formally Missouri Medicaid) programs  - A state program that helps with medical costs for some people with low incomes and limited resources. It offers several different plans based on the needs and/or choices of the patient.

Medicare - A federal program for the disabled and for patients older than 65 who have paid into Social Security.

Medicare secondary - When a patient has private health insurance that pays first, making Medicare the secondary payer.

Medicare replacement plan - A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs or private fee-for-service plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through these plans and are not paid by Medicare.

Self-payment or self-pay - Self-Pay is any amount of the patient’s charges that is the patient’s responsibility.

Workers’ compensation - A system of compensation for work-related injuries, paid by employers’ contributions to a workers’ compensation fund.

Third-party liability - Third-party liability (TPL) refers to the legal obligation of third parties (certain individuals, entities or programs) to pay all or part of medical expenses before other insurers or payers.

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