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SolveYourProblem
eLearning Series:
Health Insurance: Your Questions Answered
What does everything mean & how
to choose the right policy
( 18 pages )
HEALTH
CARE & HEALTH INSURANCE
GLOSSARY OF TERMS
Coinsurance: The
amount you are required to pay for medical care in a fee-for-service
plan 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.
Co-payment: Another
way of sharing medical costs. You pay a flat fee every time
you receive a medical service (for example, $5 for every
visit to the doctor). The insurance company pays the rest.
Covered
Expenses: 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.
Deductible: The
amount of money you must pay each year to cover your medical
care expenses before your insurance policy starts paying.
Exclusions: Specific
conditions or circumstances for which the policy will not
provide benefits.
HMO (Health
Maintenance Organization): Prepaid health plans.
You pay a monthly premium and the HMO covers your doctors'
visits, hospital stays, emergency care, surgery, checkups,
lab tests, x-rays, and therapy. You must use the doctors
and hospitals designated by the HMO.
Managed
Care: Ways to manage costs, use, and quality of
the health care system. All HMOs and PPOs, and many fee-for-service
plans, have managed care.
Maximum
Out-of-Pocket: 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, in addition
to regular premiums.
Non-cancellable
Policy: A policy that guarantees you can receive
insurance, as long as you pay the premium. It is also called
a guaranteed renewable policy.
PPO (Preferred
Provider Organization): A combination of traditional
fee-for-service and an HMO. When you use the doctors and
hospitals that are part of the PPO, you can have a larger
part of your medical bills covered. You can use other doctors,
but at a higher cost.
Pre-existing
Condition: A health problem that existed before
the date your insurance became effective.
Premium: The
amount you or your employer pays in exchange for insurance
coverage.
Primary
Care Physician: Usually your first contact for
health care. This is often a family physician or internist,
but some women use their gynecologist. A primary care doctor
monitors your health and diagnoses and treats minor health
problems, and refers you to specialists if another level
of care is needed.
Provider: Any
person (doctor, nurse, dentist) or institution (hospital
or clinic) that provides medical care.
Third-Party
Payer: Any payer for health care services other
than you. This can be an insurance company, an HMO, a PPO,
or the Federal Government.
 
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