Federal legislation that requires employers
with 20 or more employees to offer employees (and/or dependents)
to continue coverage under the group plan for eighteen
to 36 months.
In California, Cal-COBRA applies
these regulations to employers with 2 or more eligible
employees.
Co-Insurance
The percentage of covered expenses an insured
person shares with the carrier. (i.e., for an 80/20 plan,
the health plan member's co-insurance is 20%.) Co-insurance
starts after the insured pays any deductible and is only
required up to the plan's stop loss amount. (see "stop
loss.")
Co-pay/Co-payment
The amount a subscriber 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,
or $250 for a hospital admission fee.
Deductible
Amount of covered medical bills that must
be paid by subscriber before the insurance company starts
sharing expenses. Unless otherwise noted, deductibles
are on a calendar year basis.
Deductible
WAIVED
Some benefits are available with the deductible
set aside. These typically include well care exams for
adults and children, prescription drugs, and office visit
fees.
Health
Maintenance Organization (HMO)
An insurance that stresses affordable benefits
for preventive care, early diagnosis and treatment on
an outpatient basis. Typical HMO benefits have no deductible
for out patient care. The office co payment usually covers
all services performed by the doctor. Prescription drugs
are included, and hospital/surgery care is greatly discounted.
Most HMO's require enrollees to see a particular primary
care physician (PCP), who acts as the conduit to the medical
system. The PCP usually is associated with a larger number
of affiliated doctors in a medical group. The PCP will
refer the subscriber to a specialist if deemed necessary.
HMO networks are smaller than PPO networks. This restriction
in access is balanced by the affordable benefits.
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
This is the “insurance” part
of a health plan, because it defines the ceiling on the
amount you have to pay for catastrophic expenses through
deductibles and coinsurance It is the amount of expenses
paid by an individual after which the plan pays 100% for
the balance of the year. Amounts in excess of scheduled
allowances and other non-covered expenses do not count
toward the out of pocket maximum. Family out of pocket
maximums can be aggregate (the total expenses by all family
members added together) or separate (a certain number
of family members must reach their individual out of pocket
maximum to initiate the benefit). Quotes display family
aggregate out of pocket maximums as a fixed dollar amount
and separate out of pocket maximums as the number of out
of pocket maximums required per family. Deductibles are
included in the out of pocket maximum. (also
known as "stop-loss")
Preferred
Provider Organization (PPO)
A network or panel of physicians and hospitals
that contracts with an insurance company to discount its
normal fees in exchange for a source of patients. The
insured individual can choose from among the physicians
on the panel, generally without any referral. PPO plans
allow you to access specialists on your own. Typical PPO
benefits have deductibles and/or coinsurance requirements
and include prescription coverage.
Schedule
of allowable charges
Pre-determined amount the carrier will
pay for services provided by non-contracted provider.
Generally carriers set the allowable fee schedule at the
same level as the negotiated rate for contracting providers.
Since there is no contractual obligation on the part of
non-contracting providers to accept the fee schedule,
the patient is responsible for all charges in excess of
the schedule.
Short-term
medical
Temporary health coverage for an individual
for a short period of time, usually from 30 days to six
months.
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. (also known as
"Out-of-Pocket Maximum")
UCR
Short for usual, customary, and reasonable,
which is a method that some carriers use to determine
allowable charges for non-contracted providers. Usual
means the charge that a given provider usually charges,
customary means what is generally charged in the geographic
area, and reasonable takes into account extenuating circumstances.
Different carriers have various methods of calculating
UCR.
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