| A |
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- Accident and Health Insurance
- Coverage is for accidental injury, accidental death and related health expenses. Benefits pay for preventative services, medical expenses and care with limits.
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| B |
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- Benefit
- A benefit refers to the amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
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| C |
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- Claim
- Refers to an itemized statement of healthcare services and their costs, which are provided by a hospital, physician's office, or other provider. Claims are submitted to the insurer or managed care plan for payment of costs incurred either by the plan member or by the provider.
- Co-payment
- A co-payment is the member’s specified dollar amount that must be paid out-of-pocket for a specified service at the time service is provided.
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| D |
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- Deductible
- A deductible is the amount of loss paid by the policyholder. It can either be a specified dollar amount, a percentage of the claim amount or a specified amount of time that must elapse before benefits are paid. The larger the deductible, the lower the premium charged.
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| E |
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- Effective Date
- Effective date refers to the date insurance is to actually begin. Member is not covered until the policies effective date.
- Exclusions
- Exclusions refer to medical services that are not covered by an individual's insurance policy.
- Explanation of Benefits
- An Explanation of Benefits refers to the insurance company’s written explanation to a claim, which explains what they paid and what the client must pay. This is sometimes accompanied by a benefits check.
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| F |
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- Fee Schedule
- The Fee Schedule is a fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. It is sometimes referred to as a fee allowance, fee maximum, or capped fee.
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| G |
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- Generic Substitution
- A generic substitution is the dispensing of a drug, which is the generic equivalent of a drug listed on a pharmacy benefit management plans list of preferred pharmaceutical products. In the majority of situation, generic substitution can be performed without physician approval.
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| I |
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- In-network
- An In-Network refers to providers or health care facilities, which are part of a health plan's network of providers with which it has negotiated a discount. Insured individuals generally pay less when using an in-network provider, primarily because those networks provide services at lower cost to the insurance companies for which they have contracts.
- Insurance
- Insurance is a system that makes large financial losses more affordable. This is achieved by pooling the risks of many individuals and businesses by transferring them to an insurance company or other large group in return for a premium.
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| L |
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- Lifetime Maximums
- A lifetime benefit maximum is a cap placed on the amount of benefits available to a policyholder. The cap is designed so as to keep the cost of benefits affordable as well as to stabilize future costs. Some health plans cap lifetime benefits at $1 million. Others have lifetime maximums of $2 million or $5 million.
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| N |
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- Network
- A Network refers to the group of physicians, hospitals, and other medical care providers that a certain managed care plan has contracted with and which delivers medical services to its members.
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| O |
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- Outpatient Care
- Outpatient care refers to treatment that is provided to a patient who can return home after care without having to stay overnight in a hospital or other inpatient environment.
- Out-of-Plan
- This phrase refers to physicians, hospitals or other health care providers who are considered non-participants in an insurance plan (usually an HMO or PPO). Expenses incurred by services provided by out-of-plan health professional may not be covered or if covered, only in part by an individual’s insurance company.
- Out-of-Pocket Limits
- The Out-of-Pocket limit is the maximum amount that a member must pay for covered medical expenses each plan year. These include deductible and co-payments for hospital inpatient admissions and outpatient surgery.
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| P |
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- Patient Bill of Rights
- Refers to the Consumer Bill of Rights and Responsibilities, a report prepared by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. In an effort to ensure the security of patient information, promote healthcare quality, and improve the availability of healthcare treatment and services, the report posts a number "rights," which have been subdivided into eight general areas which guaranteed that consumers have the right to receive accurate, easily understood information.
- Pre-existing Conditions
- A Pre-existing Condition refers to a medical condition that was believed to exist prior to the individual obtaining a policy from the particular insurance company and is therefore excluded from coverage by an insurance company.
- Premium
- A Premium is a prepaid payment or series of payments made to a health insurer by policyholders for health insurance coverage.
- Primary Care Provider (PCP)
- Refers to a physician or other medical professional that serves as the policyholder’s first contact with a plan's healthcare system. It is also acknowledged as a primary care physician, personal care physician, or personal care provider.
- Provider
- Provider is a term used to define health professionals who provide health care services. The term sometimes refers only to physicians but it can also refer to other health care professionals including hospitals, nurse practitioners, chiropractors, physical therapists, and other services offering specialized health care services.
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| U |
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- Underwriting
- Underwriting is the process of identifying and classifying the risk represented by an individual or group.
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