Terms

1. Coinsurance
2. Coordination of Benefits
3. Copayment
4. Covered Expenses
5. Customary Fee
6. Deductible
7. Exclusions
8. HMO
9. Managed Care
10. Maximum Out Of Pocket Expenses
11. Non-cancelable Policy
12. PPO (Preferred Provider Organization)
13. Pre-existing Condition
14. Premiums
15. Primary Care Doctor
16. Provider?
17. Third-Party Payer

Coinsurance (return to top)

After you have met your insurance deductible, this is the amount that you would be responsible for paying for any medical care, service or fees. A coinsurance rate is usually described as a percentage where the insurance covers 80 percent and you would cover 20 percent.

Coordination of Benefits (return to top)

When you are covered under more than one group health insurance plan or medical insurance plan this is the system that coordinates the benefits. Usually, claims set up under two health insurance plans limit the benefit payment to no more than 100 percent of the health claim.

Co-payment (return to top)

This is a shared medical cost between you and the insurance provider. You pay a set amount for a medical service and the insurance provider pays the rest. You might have a co-pay amount of $10-$15 for a doctor's visit or whatever amount is set by your insurance provider.

Covered Expenses (return to top)

Not all health care services are paid for by health insurance plans, whether they are fee-for-service, HMOs, or PPOs. Some may not pay for prescription drugs while others may not pay for mental health care. Covered health care services are those medical services and procedures the health insurer agrees to pay for. They are usually listed in your health insurance policy. Contact your insurance carrier for all services that are covered under your plan.

Customary Fee (return to top)

Insurance companies pay only what they call a csutomeray fee or what is a reasonable fee for health care services. If most doctors in your area are charging a lower rate than your current physician for a specific procedure, then the insurance company may elect to pay the lower rate, or what is customary for your area. You would be responsible for paying the difference in addition to your deductible amount. You may elect to shop around for another physician that has a lower fee for the procedure or ask your current doctor if he will lower his cost to match what the insurance provider will pay.

Deductible (return to top)

This is the amount that you will be responsible for before your insurance company pays the balance. If you have a decutible amount of $500, then you pay the first $500 and the insurance company will pay the balance. Since each plan is different contact your insurance provider to see what deductible amounts are available on your plan.

Exclusions (return to top)

Specific procedures or conditions can be excluded from coverage by your insurance provider and they will not provide benefits. Check with your insurance provider to verify what specific exclusions are not covered on your plan.

HMO (Health Maintenance Organization) (return to top)

HMO's are prepaid health insurance plans where you pay a monthly premium and the HMO covers your doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. Usually you are limited to specific doctors and hospitals designated by the HMO plan.

Managed Care (return to top)

Managed care are ways to manage costs and the quality of health care systems. All HMOs and PPOs, and many fee-for-service plans have managed care.

Maximum Out-of-Pocket Expenses (return to top)

This is the maximum amount of money that you would be required to pay for any deductible or coinsurance amounts in a year. It us usually an amount set by the insurance provider.

Non-cancellable Policy (return to top)

This is a type of policy that guarantees you will receive health insurance as long as you keep paying the insurance premium. It can also be called a guaranteed renewable policy.

PPO (Preferred Provider Organization)(return to top)

Usually under this type of provider, a larger part of your medical fees are covered by the provider if you use physicians and hospitals that are part of the PPO. If you use physicians and hospitals outside of the PPO, then you could pay a higher fees.

Pre-existing Condition(return to top)

When a health issue existed before the date your health insurance policy became effective it is called a pre-exiting condition. It existed before you obtained any health insurance.

Premiums(return to top)

This is the amount that you pay to your health insurance provider in exchange for them covering your medical payments.

Primary Care Doctor(return to top)

Your primary care doctor is your family physician or other first care doctor who monitors your health conditions on a routine basis. If you need more specialized care, then they are the doctors that refer you to a specialist. Many health insurance plans will only pay fees under a specialists care if you are referred by your primary care doctor. An HMO or a POS plan will provide you with a list of doctors from which you can choose your primary care doctor, a family physician, internists, obstetrician-gynecologist, or pediatrician. If you change plans, you may have to choose a new primary care doctor if your current one does not belong to the health insurance plan.

Provider(return to top)

A provider can be any doctor, nurse practitioner, dentist, hospital or clinic that provides medical care and services.

Third-Party Payer(return to top)

Third party payers can be health insurance companies, HMO or PPO, or the Federal Government that pays for your health care services.

Terms

1. Managed Care Plans
2. HMO (Health Maintenance Organizations)
3. Fee-For-Service Health Plans
4. PPO (Preferred Provider Organizations)
5. POS (Point of Service Plans)

Managed Care Plans(return to top)

Health Insurers help control costs through managed care plans. The insurance provider can monitor if a medical service or procedure is necessary and cost effective. If you need medical services or need to go to the hospital, your insurance provider may require you to pre-approve this service or hospital admittance prior to being admitted or having the service performed. If the service or hospital stay is done without approval you would be responsible for the fees.

HMO (Health Maintenance Organizations)(return to top)

An HMO is a pre-paid health plan. You pay a monthly premium in exchange for comprehensive medical care. This usually includes all doctor's visits and medical services. The HMO usually has physicians and facilities that have agreements to provide care under the HMO plan. You are provided a list of these providers to choose from when you need care. Exceptions are granted for emergency care and medical emergencies. If you elect to use physicians and facilities not under the HMO umbrella, you could be denied coverage or pay extra fees for their services. HMO's usually require a co-payment for services, but your total medical costs could be lower and more consistent in what you pay for services.

Under an HMO plan, you may not have to file a claim for medical services. You present an identification card to the physician or facility, pay any co-payment fees, and the balance is paid for by the HMO.

Fee-For-Service Health Plans(return to top)

With these common health insurance plans, you pay a premium to the health insurance provider in exchange for coverage of health insurance. The insurer pays only part of your doctor and medical services and you pay the rest called co-insurance. Typically the insurer pays 80% and you pay 20%, depending upon the plan selected, after you have met your deductible. Deductibles and plans vary and coverage could be limited to how much an insurance provider will pay depending upon the circumstances and exclusions. Most fee-for-service plans have a "cap" which is the most you would have to pay in one year for any medical expenses, outside of your monthly premium payments.

There are two kinds of coverage, basic and major medical. Basic coverage includes most short term hospital stays, doctor's visits, services and supplies, while the major medical takes over where the basic coverage leaves off. Usually, major medical covers the cost of long and high-cost illnesses or injuries. Consult with your insurance carrier to determine what limitations and exclusions are covered under basic and major medical portions.

You, your physician or medical facility normally files a claim for any insurance coverage to the insurance provider to collect payment.

PPO (Preferred Provider Organizations)(return to top)

Preferred providers are a combination of traditional Fee-for-Service plans and an HMO. There are limited number of physicians and facilities where most of your medical services are covered. You choose a primary care physician that the PPO will cover preventive care. In most cases, you present your identification card, pay any co-payment amounts, and the PPO provider covers the balance. However, with certain health care services, you may have to pay a deductible and coinsurance amount and providers may require a claim for for coverage. You can usually use physicians and facilities not under the PPO plan, however, you can expect to pay a larger portion of the bill yourself.

POS (Point of Service Plans)(return to top)

Point of Service Plans are an indemnity type plan offered by HMO's. If you are a member of a POS, you don't necessarily need a physician's referral, you can refer yourself to an out of plan physician and still have coverage by the health plan. If a physician makes a referral to an out of network physician or facility, the service is covered, but you may have a coinsurance to pay.