mathematician in the insurance field. An actuary is responsible
for calculating premiums and defining underwriting risk.
Prescription drug, which is marketed with
a specific brand name by the company that manufactures it.
It usually costs individuals higher co-pay than generic drugs.
licensed insurance professional who obtains multiple quotes
and plan information in the interest of his client. Client's
Company or HMO insuring the health plan.
Consolidated Omnibus Budget Reconciliation Act of 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. For more information
see COBRA FAQ .
amount you are required to pay for medical care after you have
met your deductible. The coinsurance rate is usually expressed
as a percentage. For example, if the insurance company pays
80 percent of the claim, you pay 20 percent. Coordination of
Benefits: A system to eliminate duplication of benefits when
you are covered under more than one group plan. Benefits under
the two plans usually are limited to no more than 100 percent
of the claim.
Another way of sharing medical costs.
You pay a flat fee every time you receive a medical service
(for example, $20 for every visit to the doctor). The insurance
company pays the rest. This benefit is usually available
without having to satisfy the plan deductible.
Most insurance plans, whether they are fee-for-service,
HMOs, or PPOs, do not pay for all services. Some may not
pay for prescription drugs. Others may not pay for mental
health care. Covered services are those medical procedures
the insurer agrees to pay for. They are listed in the policy.
amount of money you must pay each year to cover your medical
care expenses before the plan begins paying co-insurance benefits.
Co-pays benefits are usually payable before satisfying the
conditions or circumstances for which the policy will not provide
benefits. These will be listed in the sales brochure and policy.
A carrier's written response to
a claim for benefits. Sometimes accompanied by a benefits
The chemical equivalent to a "brand name drug." These
drugs cost less, and the savings is passed onto health plan
members in the form of lower co-pay.
Health Insurance Portability and Accountability Act (HIPAA)
provides rights and protections for participants and beneficiaries
in group health plans. HIPAA includes protections for coverage
under group health plans that limit exclusions for preexisting
conditions; prohibit discrimination against employees and dependents
based on their health status. HIPAA may also give you a right
to purchase individual coverage if you have exhausted COBRA
or other continuation coverage. For more information, see HIPAA
health plans in which you pay a monthly premium and the HMO
covers your doctors' visits, hospital stays, emergency care,
surgery, preventive care, checkups, lab tests, X-rays, and
therapy. You must choose a primary care physician (PCP) 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 are in your plan's network. No benefits are
paid for care received outside of the HMO network.
Card given to insured individuals, which advises
medical providers that a patient is covered by a particular
health insurance plan.
cap on the benefits paid by the insurance
company 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 of the
of financial loss.
The coordination of health care services to
produce high quality health care for the lowest possible
cost. Examples are the use of primary care physicians (PCP)
as gatekeepers in HMO plans and pre-certification of hospital
stays and certain surgical procedures in most all plans.
All HMOs and PPOs today, have some form of managed care.
The most money you will be required
pay a year for deductibles and coinsurance. It is a stated
dollar amount set by the insurance company. Co-pays for Dr.
office visits and prescriptions are in addition to this maximum
A tax-advantaged personal savings
account used along with a high deductible health policy.
You may deposit money into this account on a pre-tax basis
to set aside money for medical care and expenses that qualify,
including annual deductibles and co-payments.
group of doctors, hospitals and other healthy care providers
contracted to provide services to an insurance company's members
at discounted fees. Provider networks can cover large geographic
markets and/or a wide range of health care services. In most
all health plans, members typically receive a higher benefit
level for using a network provider.
A policy that guarantees you can keep your
insurance, as long as you pay the premium. It is also called
a guaranteed renewable policy.
provider of health care services that is not part of a health
plan's network. Individuals usually receive a lower benefit
level when using an out-of-network provider.
The most money you will pay in a year for
deductibles and co-insurance. Co-pays for Dr. office visits
and prescriptions are in addition to this maximum amount.
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 decisions generally remain with the patient
as he or she selects providers and determines his or her
own need for services. Patients have financial incentives
to select providers within the PPO network.
companies require pre-approval of non-emergency hospital admission
and certain surgical procedures to verify necessity and appropriateness.
Pre-certification is a part of all health plans today.
A health problem that existed before the
date your insurance became effective. The specific definition
and waiting period varies with each individual insurance
amount you pay for insurance coverage.
In an HMO plan, usually your
first contact for health care. This is often a family physician
or internist. A primary care doctor monitors your health,
diagnoses and treats minor health problems, and refers you
to specialists if another level of care is needed.
physicians, hospitals or outpatient facility providing health
care services. Usually licensed by the state.
Any payer for health care services other than
you. This can be an insurance company, an HMO, a PPO, or
the Federal Government.
HMO plans - the insured individual must get an approval (referral)
from their Primary Care Physician (PCP) in order to be seen
by a specialist within the HMO.
Temporary health coverage for an individual
for a short period of time, usually from 30 days to six months.
State laws requiring that health
insurance plans include specific benefits.
point at which an individual has reached their maximum out-of-pocket
limit of their plan. This is when the insurance company begins
to pay eligible expenses at 100%.
company employee, who reviews applications, evaluates risk
and makes decision to approve or decline coverage.
an individual has a specific pre-existing condition when applying
for new coverage, sometimes the Insurance Company may offer
to issue a policy, but exclude coverage for that condition
for a period of time.
Insurance coverage for work-related
illness and injury. All states require employers to carry
a provider or health care facility, which is part of a health
plan's network. Individuals usually pay less when using an
insurance company's restrictions on the amount of benefits
paid out for in certain situations. These will be listed in
the sales brochure and policy.