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A method of paying medical providers through a pre-paid, flat monthly fee for each covered person. The payment is independent of the number of services received or the costs incurred by a provider in furnishing those services.
The formal request by a policy holder or claimant to be paid under the terms of the insurance policy.
The Consolidated Omnibus Budget Reconciliation Act 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for you and your dependents for 18 months after you leave your job. Longer durations of continuance are available under certain, circumstances. If you opt to continue coverage, you must pay the entire premium, plus a two percent administration charge.
The amount you are required to pay for medical care in fee-for-service plan or preferred provider organization (PPO) after you have met your deductible. The coinsurance rate is usually expressed as a percentage of billed charges. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
A cost sharing arrangement in which a person pays a specific charge for a specific medical service – say $10 for an office visit or $5 for a prescription.
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The amount of money you must pay upfront each year to cover your medical care expenses before your insurance policy starts paying.
A form of health insurance which pays a monthly or weekly income to you if you should become unable to work. In California, Hawaii, New Jersey, New York and Rhode Island it is an extention of their workers compensation coverage.
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The first day of a policy term. Denotes the beginning of the insurance coverage.
In employee benefits such as employer provided health and life insurance, the eligibility period is the time alloted for a new employee to enroll without having to prove insurability through health examinations. Once the the eligibility period has passed, an employee may be denied coverage based on a physical examination.
Specific conditions or circumstances for which the policy will not provide benefits.
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A payment system for health care where the provider is paid for each service rendered.
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Prepaid health plans in which you pay a monthly premium and the HMO covers your doctor’s visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, x-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan’s network.
An HSA works like an IRA, except that money is used to pay health care costs. Participants enroll in a relatively inexpensive high deductible insurance plan. Then, a tax-deductible savings account may be opened to cover current, and future medical expenses. The money deposited, as well as the earnings, is tax-deferred. The money can then be withdrawn to cover qualified medical expenses tax-fee. Unused balances roll over from year to year.
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Typically used in life insurance to indicate the termination of a policy.
A cap on the benefits paid under a policy. Many policies have a lifetime limit of $1 million, which means that the insurer agrees to cover up to $1 million in covered services over the life other policy.
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A type of health insurance designed to cover catastrophic medical expenses. A major medical policy can be your only health policy or supplemental to another health insurance policy with low payout limits.
An organized way to manage costs, use, and quality of the health care system. The major types of managed care plans are health maintenance organizations (HMOs), point-of-service (POS) plans and preferred provider organizations (PPO).
A joint federal-state health insurance program that is run by the states and covers certain low-income people (especially children and pregnant women), and disabled people.
A general liability coverage in which the insurer reimburses without regard to the insured's liability, the insured and others (as specifically provided in the policy) for medical and funeral expenses incurred by such persons as a result of bodily injury or death sustained by accident under the conditions specified in the policy.
The federally sponsored health insurance program of hospital and medical insurance primarily for people age 65 and over.
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The period of time in which new subscribers may enroll in a health insurance plan.
The most money you will be required to pay in a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
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A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a flat dollar co-payment (say $10 for a doctor’s visit), or to an out-of-network provider and pay a deductible and/or coinsurance charge.
A formal contract outlining the terms and conditions of the insurance provided by an insurance carrier.
The ability for an individual to transfer from one health insurance to another heath insurance with regard to pre-existing conditions or other risk factors.
A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization or surgery and receive authorization for the service.
A health problem that existed before the date your insurance became effective. Many insurance plans will not cover preexisting conditions. Some will cover them only after a waiting period.
Preferred Provider Organization (PPO)
A network of health care providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Health care decision generally remains with the patient as he she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network.
The amount you or your employer pays in exchange for insurance coverage.
Under a health maintenance organization (HMO) or point-of-service (POS) plan, usually your first contact for health care. This is often a family physician, internist, or pediatrician. A primary care physician monitors your health, treats most health problems, and refers you to specialists if necessary.
Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that provides medical care.
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An employee benefits plan that meet the requirements set forth in IRS Code Section 401a. Employer contributions to qualified plans are tax deductible.
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Any payer of health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government.
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The amount a health plan will recognize for payment for a particular medical procedure. It is typically based on what is considered “reasonable” for that procedure in your service area.
A cost control mechanism by which the appropriateness, necessity, and quality of health care services are monitored by both insurers and employers.
