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Glossary of Terms |
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Ancillary Services - services, other than those provided by a physician or hospital, which are related to a patient’s care, such as laboratory work, x-rays and anesthesia. Calendar Year - the period beginning January 1 of any year through December 31 of the same year. Case Management - a process whereby a covered person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner. Certificate of Coverage - a document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company. Claim - Information a medical provider or insured submits to an insurance company to request payment for medical services provided to the insured. Coinsurance - The portion of covered health care costs for which the covered person has a financial responsibility, usually a fixed percentage. Coinsurance usually applies after the insured meets his/her deductible. Consolidated Omnibus Budget Reconciliation Act (COBRA) - a federal law that, among other things, requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance has been terminated if they undergo a triggering event. Contract Year - the period of time from the effective date of the contract to the expiration date of the contract. Coordination of Benefits (COB) - a provision in the contract that applies when a person is covered under more than one medical plan. It requires that payment of benefits be coordinated by all plans to eliminate overinsurance or duplication of benefits. Copayment - a cost-sharing arrangement in which an insured pays a specified charge for a specified service, such as $10 for an office visit. The insured is usually responsible for payment at the time the service is rendered. This charge may be in addition to certain coinsurance and deductible payments. Covered Person- an individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement. Deductible - the amount of eligible expenses a covered person must pay each year from his/her own pocket before the plan will make payment for eligible benefits. Deductible Carry Over Credit - charges applied to the deductible for services during the last 3 months of a calendar year which may be used to satisfy the following year’s deductible. Dependent - a covered person who relies on another person for support or obtains health coverage through a spouse, parent or grandparent who is the covered person under a plan. Effective Date - the date insurance coverage begins. Eligible Dependent - a dependent of a covered person (spouse, child, or other dependent) who meets all requirements specified in the contract to qualify for coverage and for who premium payment is made. Eligible Expenses - the lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan. Explanation of Benefits (EOB) - the statement send to an insured by their health insurance company listing services provided, amount billed, eligible expenses and payment made by the health insurance company. Insured - a person who has obtained health insurance coverage under a health insurance plan. Managed Care - a health care system under which physicians, hospitals, and other health care professionals are organized into a group or “network” in order to manage the cost, quality and access to health care. Managed care organizations include Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). Out-of-Pocket Maximum - the total payments that must be paid by a covered person (i.e., deductibles and coinsurance) as defined by the contract. Once this limit is reached, covered health services are paid at 100% for health services received during the rest of that calendar year. Participating Provider - a medical provider who has been contracted to render medical services or supplies to insureds at a pre-negotiated fee. Providers include hospitals, physicians, and other medical facilities. Preferred Provider Organization (PPO) - a health care delivery arrangement which offers insureds access to participating providers at reduced costs. PPOs provide insureds incentives, such as lower deductibles and copayments, to use providers in the network. Network providers agree to negotiated fees in exchange for their preferred provider status. Provider - a physician, hospital, health professional and other entity or institutional health care provider that provides a health care service. Primary Care Physician (PCP) - a physician that is responsible for providing, prescribing, authorizing and coordinating all medical care and treatment. Reasonable and Customary (R &C) - a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. Underwriting - the act of reviewing and evaluating prospective insureds for risk assessment and appropriate premium. |
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* Please review your policy for each carriers exact definitions |
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