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Selling, General and Administrative Expenses (SG&A): Refers to insurer operating costs--not the actual cost of medical costs associated with member benefits.
Sanction: Stands for a reprimand or disciplinary measure imposed on doctors or other healthcare providers from state licensing authorities or professional organization for either conduct unbecoming of a professional or for incompetent performance.
Second Opinion: Often, a patient will seek the medical opinion of an alternative medical caregiver in reference to a diagnosis or proposed medical treatment provided by the patient's initial healthcare provider(s). This may be a formal process, or the patient may simply initiate the second visit for reasons of their own.
Secondary Care: Refers to services provided by secondary medical caregivers like dermatologists, cardiologists, or other medical specialists. See also tertiary care.
Secondary Coverage: An insurance plan that accepts financial responsibility for qualified charges that the primary benefit plan does not cover. See coordination of benefits.
Section 125 Plan: Refers to flexible benefit plans. These plans are typically used to allow employees to pay their health insurance premiums with pre-tax dollars. See flexible spending account.
Section 1876: Section of the Social Security Act that allows Medicare risk.
Section 1833: Section of the Social Security Act that enables the HCPP to initiate agreements.
Self-Funding, Self-Insurance: Healthcare program that allows employers to fund insurance plans with their own resources and without purchasing an insurance product. Self-funded plans can be self-administered, or the employer may use an outside administrator. Self-funding employers may limit their liability using stop-loss insurance.
Service Area: Geographic service area outlined by a health insurance plan and approved by state regulators.
Sickness: Refers to a physical or mental illness (note that pregnancy is generally paid under the sickness benefit). Single Carrier Replacement: This model or process covers qualifying employees via one insurance provider.
Single-Payer System: A healthcare financing agreement where funds are funneled to an entity (often the government) that assumes responsibility for financing and providing administrative functionality for the health system. Single payer systems may be nationwide or statewide.
Skilled Nursing Facility (SNF): A facility that provides rehabilitation medical services or provides less-intensive medical care for patients discharged from a hospital setting.
Small Group Pooling: The process of combining small group businesses into several pools or a single pool. The pool determines expected claims and premium rates.
Staff Model HMO: Healthcare model that employs healthcare providers to deliver medical care to its members. The HMO provides physicians with a salary as well as incentive programs.
Standard Benefit Package: Refers to a set of healthcare benefits offered via delivery systems. These packages may include medical care services, hospital services, preventative care, prescription drugs, and mental healthcare services.
Standard Class Rate (SCR): Refers to the base revenue requirement associated with a per employee basis and multiplied by group information to provide premium rates.
Standard Prescriber Identification Number (SPIN): Developed by the National Council of Prescription Drug Programs to identify prescribers.
Stop-Loss Insurance: Refers to health insurance coverage that may be self-funded by an employer as a protection against medical claims that are greater than a specified amount for each covered person. There are different types of stop-loss insurance including specific reimbursement plans and aggregate plans. See also Reinsurance.
Sub-Acute: A facility that provides patients with an overnight stay but does not deliver the intensive attention or range or medical resources associated with a hospital stay.
Subrogation: Insurers use this procedure to recover a portion of paid benefits from third parties. See Enrollee for related information.
Subscriber Contract: See Certificate of Coverage
Substance Abuse: Refers to situations where individuals use alcohol, illicit drugs, or prescription drugs in a manner that puts their physical, mental, social, and economic well-being at risk. Substance abuse may also be referred to as substance addiction or chemical dependency.
Substance Abuse Treatment Plans: These health plans provide partial, or all of the costs associated with addiction treatment at an addiction treatment center, drug rehab center, or hospital for individuals who are addicted to drugs or alcohol. In most cases, the benefit will not be assumed without an inpatient stay for treatment. In other words, outpatient treatment may not qualify or may not qualify without the accompanying inpatient stay.
Summary Plan Description: This description provides an explanation of a benefits package. ERISA requires employers to present this description to enrollees.
Supplemental Services: Refers to optional healthcare services that a health insurance plan may cover in addition to basic medical care services.
Surgi-Center: See Outpatient Surgical Center