Large Claim Pooling

System that isolated claims above a certain level and charges them to a pool funded by charges of all groups who share the pool. Designed to help stabilize significant premium fluctuations.

Legend Drug

Drug that the law says can only be obtained by prescription. y.

Limiting Charge

The maximum amount that a non-participating physician is permitted to charge a Medicare beneficiary for a particularly defined procedure or bundled service. These limits are published by the individual state intermediaries for Medicare and HCFA and are usually combined in reports with the allowed charges and regional payment schedules. In 1993,  the limiting charge was set at 115 percent of the Medicare-allowed charge. However, this does not reflect what the physician will be paid.

Lock-in

A contractual provision by which members are required to use certain health care providers in order to receive coverage (except in cases of urgent or emergent need).

Long-term care

A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g., the chronically ill, aged, disabled, or retarded) in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals. Ambulatory services such home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.

Long term care insurance

Insurance designed to pay for some or all of the costs of long term care.

Loss Ratio

Incurred claims plus expenses, divided by paid premiums. See also Incurred Claims Loss Ratio.