Glossary: Health insurance & self-insurance terms to know

Sana uses a self-insured model to serve its clients. Here are some terms that will be helpful to know as you learn more about how our service works:

Health Insurance Carrier
Also known as health insurance companies. With traditional insurance plans, a carrier is the company that holds your insurance policy. Your company pays a monthly fee for the carrier to pay claims and administer benefits.

Self-insured Health PlanAn employer-sponsored health plan, where an employer assumes responsibility for paying health claims directly. Most large employers use self-funded plans, and small employers can self-fund using a level-funded model.

Medical Claims
Also known as health care claims. A claim is essentially your provider’s invoice for services performed. When working with a carrier, your claim is sent to and paid by the carrier. When using a self-insurance model, your company or TPA manages your claims.

Third Party Administrator
Also known as a TPA or plan administrator. Companies with a self-insurance plan often partner with a TPA. The TPA provides support in securing, administering, and managing your benefits plan.

Level Funded plans are self-funded plans generally used by small and mid-size employers. Your company pays a fixed, or level, monthly amount for each employee’s benefits, similar to traditional insurance, and you only pay for what you use.

Stop Loss Insurance
Stop loss insurance kicks in when excessively large claims arise. It helps carriers or TPAs cover any overage in expected costs, so your company is protected.

A provider is a licensed professional that provides health care services, usually by partnering with health insurance companies to be part of a preferred network. Providers include licensed doctors of medicine or osteopathy, podiatrists, dentists, clinical psychologists, chiropractors, and more.

Also known as ‘limitations and exclusions.’ Exclusions refer to the medical expenses that your carrier does not cover. An exclusion can refer to certain providers, types of treatments and surgeries, and medications. Exclusions vary by carrier and plan.

Also known as medical underwriting. Underwriting refers to the process of assessing the risk in providing health insurance coverage to an applicant or group. The underwriting process determines whether to offer health insurance or not, and sets the price based on the projected claims.

Affordable Care Act
Also known as the ACA or Obamacare. The ACA is the health care reform act aimed at expanding health insurance coverage to more Americans. Among other things, the ACA requires some small businesses to offer group health care coverage to their employees.