Agent - a licensed individual who represents several insurance companies and sells their products.

 

 

 

 

 

 

 

Benefit - reimbursement for covered medical expenses as specified by the plan.

 

 

 

 

 

 

 

 

Brand-name drug - prescription drug which is marketed with a specific brand name by the company that manufactures it. May cost insured individuals a higher co-pay than generic drugs on some health plans. (see "generic.")

 

 

 

 

 

 

 

 

 

Broker - a licensed insurance professional who obtains multiple quotes and plan information in the interest of his client.

 

 

 

 

 

 

 

 

 

Carrier - insurance company or HMO insuring the health plan.

 

 

 

 

 

 

 

 

 

Claim - a formal request made by an insured person for the benefits provided by a policy.

 

 

 

 

 

 

 

 

 

 

 

COBRA (Consolidated Omnibus Budget Reconciliation Act) - Federal legislation that requires group health plans to provide health plan members the opportunity to purchase continued coverage in the event their insurance is terminated. Applies only to employer groups with 20 or more employees. Learn more about COBRA at the Department of Labor's website. - Please note this may take a few minutes to appear.

 

 

 

 

 

 

 

 

 

 

 

 

 

Co-insurance - the percentage of covered expenses an insured individual shares with the carrier. (i.e., for an 80/20 plan, the health plan member's co-insurance is 20%.) If applicable, co-insurance applies after the insured pays the deductible and is only required up to the plan's stop loss amount. (see "stop loss.")

 

 

 

 

 

 

 

 

 

 

Co-pay/co-payment - the amount an insured individual must pay toward the cost of a particular benefit. For example, a plan might require a $10 co-pay for each doctor's office visit.

 

 

 

 

 

 

 

 

 

 

Deductible - the dollar amount an insured individual must pay for covered expenses during a calendar year before the plan begins paying co-insurance benefits.

 

 

 

 

 

 

 

 

 

 

 

Dependents - usually the spouse and unmarried children (adopted, step or natural) of an employee.

 

 

 

 

 

 

 

 

 

 

Effective date - the date requested by an employer for insurance coverage to begin.

 

 

 

 

 

 

 

 

 

 

 

Exclusions - expenses which are not covered under an insurance plan. These are listed in the Certificate Booklet.

 

 

 

 

 

 

 

 

 

 

 

Explanation of Benefits (EOB) - a carrier's written response to a claim for benefits. Sometimes accompanied by a benefits check.

 

 

 

 

 

 

 

 

 

 

 

Generic drug ­ 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 a lower co-pay.

 

 

 

 

 

 

 

 

 

 

Group insurance - an insurance contract made with an employer or other entity that covers individuals in the group.

 

 

 

 

 

 

 

 

 

 

 

HIPAA - Health Insurance Portability and Accountability Act of 1996, P.L. 104-91. This law relates to underwriting, pre-existing limitations, guaranteed renewal, COBRA and certification requirements in the event someone terminates from the plan. The new law, commonly known as the "Kennedy-Kassebaum Bill," establishes new requirements for self-funded, fully-insured group plans (including church plans) and Individual Health policies.

 

 

 

 

 

 

 

 

 

 

ID card/identification card - card given to insured individuals which advises medical providers that a patient is covered by a particular health insurance plan.

 

 

 

 

 

 

 

 

 

 

 

In-network - describes a provider or health care facility which is part of a health plan's network. When applicable, insured individuals usually pay less when using an in-network provider.

 

 

 

 

 

 

 

 

 

 

 

 

Lifetime maximum benefit - the maximum amount a health plan will pay in benefits to an insured individual.

 

 

 

 

 

 

 

 

 

 

 

Limitations - a restriction on the amount of benefits paid out for a particular covered expense.

 

 

 

 

 

 

 

 

 

 

 

 

Long-term disability (LTD) - insurance which pays employees a percentage of monthly earnings in the event of disability.

 

 

 

 

 

 

 

 

 

 

 

Network - a group of doctors, hospitals and other providers contracted to provide services to insured individuals for less than their usual fees. Provider networks can cover large geographic markets and/or a wide range of health care services. If a health plan uses a preferred provider network, insured individuals typically pay less for using a network provider.

 

 

 

 

 

 

 

 

 

 

 

 

Out-of-network - describes a provider or health care facility which is not part of a health plan's network. Insured individuals usually pay more when using an out-of-network provider, if the plan uses a network.

 

 

 

 

 

 

 

 

 

 

 

Out-of-pocket maximum - the total of an insured individual's co-insurance payments and co-payments.

 

 

 

 

 

 

 

 

 

 

 

 

Pre-existing condition - an illness, injury or condition for which the insured individual received medical advice, treatment, services or supplies; had diagnostic tests done or recommended; had medicines prescribed or recommended; or had symptoms of typically within 12 months (time periods may vary depending on state laws) prior to the effective date of insurance coverage.

 

 

 

 

 

 

 

 

 

 

 

Preferred Provider Organization (PPO) - A network or panel of physicians and hospitals that agrees to discount its normal fees in exchange for a high volume of patients. The insured individual can choose from among the physicians on the panel.

 

 

 

 

 

 

 

 

 

 

 

Premiums - payments to an insurance company providing coverage.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider - any person or entity providing health care services, including hospitals, physicians, home health agencies and nursing homes. Usually licensed by the state.

 

 

 

 

 

 

 

 

 

 

 

Short-term medical - temporary health coverage for an individual for a short period of time, usually from 30 days to 365 days.

 

 

 

 

 

 

 

 

 

 

State mandated benefits - state laws requiring that commercial health insurance plans include specific benefits.

 

 

 

 

 

 

 

 

 

 

 

 

Stop-loss - the dollar amount of claims filed for eligible expenses at which the insurance begins to pay at 100% per insured individual. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.

 

 

 

 

 

 

 

 

 

 

 

 

Underwriter - entity that assumes responsibility for the risk, issues insurance policies and receives premiums.