When your benefits consultant talks about your health insurance are you confused because of the terms they use? If so, this blog post will help you make sure that when they use an acronym you know what it means. As an employer or an employee it’s important to understand the terms in order to make the right decisions and be knowledgeable about your health insurance.
Here is a glossary to help you when you speak with your benefits consultant.
1. Additional Insured: Anyone covered under your health plan that is not named as “insured” in your documentation from the insurance company.
2. Benefit: The dollar amount your insurance carrier will pay when you file a claim for a covered loss.
3. Benefit Period: This is the interval during which you will be eligible for benefits. Generally, your benefit period will begin with the first medical service you received for a specific illness and end after you have not been treated for that condition for 60 days.
4. Carrier: The insurance company you receive your health plan from.
5. Certificate of Insurance: This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier. It spells out precisely what will be covered, what won’t, and the dollar maximums.
6. Claim: This refers to any request to your insurance company for benefits.
7. COBRA: This acronym refers to the Consolidated Omnibus Budget Reconciliation Act of 1985. The law requires group medical plans covering twenty employees or more to offer participants the option to receive continued healthcare benefits for up to eighteen months after the cancellation of their group plan.
8. Co-payment: This is a cost-sharing arrangement in which you will be responsible for a specific charge for a specific medical service ($20.00 per office visit, or $10.00 per generic prescription).
9. Covered Expenses: The various medical procedures that your insurer has agreed to provide you coverage for.
10. Deductible: The amount you’ll be required to pay for healthcare expenses before your insurance plan will begin to reimburse you.
11. Exclusion: A specific circumstance or condition that is not covered by your policy.
12. Effective Date: This refers to the date on which your insurance coverage will actually begin to cover you.
13. Fee-for-Service: This is a payment system for healthcare where your provider is paid for each service after it is performed. You receive reimbursement after you file a claim.
14. HMO: Health Maintenance Organization. HMO’s are popular health benefit programs in which you’ll pay monthly premiums in return for managed coverage for your checkups, hospital stays, doctors’ visits, surgery, emergency care, preventive care, lab tests, and X-rays. If you join an HMO, you will have to select what’s called a “Primary Care Physician” who will be responsible for coordinating your healthcare and making any referrals to specialists that you require. You’ll also have to use doctors, hospitals and clinics who are members of your HMO plan’s network.
15. In-network: Healthcare facilities or providers who are members of your health plan.
16. Lifetime Limit: This refers to the cap (or maximum level) on benefits available through a policy.
17. LOS: This is an acronym for the term “length of stay”. It’s used by insurance carriers, case managers, and other healthcare professionals to describe the length of time any individual spends in a hospital or an in-patient care facility.
18. Maximum Out-of-Pocket Expenses: The most you will have to pay during one year — in the form of deductibles and coinsurance fees.
19. Managed Care: This term refers to an increasingly broad assortment of health plans that manage healthcare costs and usage. There are three major types of managed health plans: HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and POS (Point-Of-Service plans).
20. Medicaid: This is a joint state/federal health insurance program that is administered by the state. It provides health coverage for low-income individuals, especially pregnant women, children and the disabled.
Stay tuned for part 2 with more terms.