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Insurance
Vocab
| Term | Definition |
|---|---|
| Coinsurance | how you or your medical plan share cost after you meet the plan annual deductible. Ex. your plan covers 80%, leaving you responsible for 20%. this 20% is your coinsurance. |
| Copay | fixed amount (for example $25) you pay for a cover healthcare service, usually when you receive the service. The amount can vary by the type of service you receive. |
| Deductible | amount you owe for healthcare services before your plan begins to pay. the exception is preventive care, which is fully covered so you pay nothing, and any copay or services for which the deductible is waived. |
| out-of-pocket maximum | protects you financially by capping the amount you'll pay in a plan year for covered health expenses. If you reach your medical plan's out-of-pocket maximum, your plan pays 100% of covered services for the rest of the year. |
| Premiums | fixed amount that you automatically contribute from each paycheck for coverage under a medical plan. Premiums can vary widely by the type of plan you choose. |
| Assignment of benefit | the payment of health insurance benefits to a healthcare provider rather than directly to the member of a health insurance plan |
| Coordination of Benefit (COB) | this is a process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance plan |
| Carrier | any insurer, managed care organization, or group hospital plan, as defined by applicable state law. |
| Claim | a bill for medical services rendered, typically submitted to the insurance company by a healthcare provider. |
| Explanation of Benefits (EOB) | statement sent from the health insurance company to a member listing services that were billed by a healthcare provider, how those changes were processed, and the total amount of patient responsibility for the claim. |
| Health Maintenance Organization (HOM) | you will need to choose a primary care physician (PCP) who will provide most of your health care and refer you to HMO specialist as needed. Some HMO plans require you to fulfill a deductible before service. Other only require you to make a copayment. |
| Managed Care | The management of healthcare is intended to keep costs and monthly premiums- as low as possible. there are several different types of managed care health insurance plans, including HMO, PPO, and POS plans. |
| Medicaid | A state-funded health care program for low income and disabled persons. |
| Medicare | a national, federally administered health insurance program authorized in 1965 to cover the cost of hospitalization ,medical care and some related health services for most people over age 65 and certain other eligible individuals. |
| Preferred Provider Organization | Plan you will need to get your medical care from doctors or hospitals on the insurance company's list of preferred providers if you want your claims paid at the highest level. Services render by out of network providers not covered or may be paid lower. |
| Participating Provider | Generally, this term is used in a sense synonymous with Network provider. Some providers contracting with insures at lower levels may sometimes be referred to as "participating providers" as opposed to "preferred providers". |
| Member | anyone covered under a health insurance plan, an enrollee or eligible dependent. |
Created by:
maria_serv
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