 |
 |
 |
 |
   |
The following should not be construed as the legal definitions for federal or state statutory or regulatory terms. The brief explanations of the following terms are in plain language to facilitate understanding by the viewing public.
COBRA See Consolidated Omnibus Budget Reconciliation Act of 1986. Coinsurance The amount you are required to pay for medical care after you satisfy the annual deductible, if any. It is usually expressed as a percentage of billed charges. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent. Co-payment A specific charge you pay for a specific medical service. For example, you may pay only $15 for an office visit or $10 for a prescription drug and the health plan covers the rest of the medical charges. Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 Legislation providing for a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued for up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may be continued for up to 36 months in nearly all other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age. Deductible The amount each insured (employee) pays for covered expenses first, before an insurance plan begins to pay benefits. Deductibles can apply to all services or limited types of services. Not all plans require a deductible. Exclusions Exclusions are specific conditions or circumstances for which the policy will not provide benefits. Employer Wage and Tax Statement Employer tax reporting statement submitted to the applicable state agency to establish and report the employer's tax responsibilities. Enroll/ Enrolling Employees Employees enroll in a group health plan by selecting from the health plan options offered by the employer and signing the appropriate forms provided to the employer by the insurance company. Enrolling employees are the number of employees that participate in a group health plan. Fee-for-Service A method of charging for each visit or service. This method is arranged between a physician and the insurance company. Formulary A list of medications that your provider may prescribe that would be covered under the pharmacy benefit at a low co-payment. Formularies are used to control rising medical costs and keep co-payments low but still provide the best value and not compromise quality of care. HMO (Health Maintenance Organization) An organization that provides a wide range of comprehensive health care services through a designated group, or network of doctors, hospitals, labs and other providers. To receive benefits, you must first see the Primary Care Physician you selected for care or a referral, except in the case of an emergency. Your choice of doctors is restricted to those in the network. If you are an HMO member and you do not use the doctors, hospitals and clinics that participate in your plan's network, you will usually bear the cost of those medical services. Lifetime Maximum Maximum amount of benefits available to a member during their lifetime. All benefits furnished are subject to this maximum unless stated as unlimited. HSA (Health Savings Account) A tax-advantaged personal savings account used in conjunction with a high deductible health policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses, including annual deductibles and co-payments. This can be set up through your CPA or tax advisor. Out-of-Pocket Maximum The most money you pay for covered expenses during the year before the plan begins paying 100% of covered expenses for the remainder of the year. Only covered expenses count toward the maximum. For example, any charges above the limited fee schedule for out of network doctor's services do not count. Part-time Employees To the purposes of qualifying for group insurance, a part-time employee is an employee working less than 30 hours per week. Point-of-Service (POS) Plan A plan that combines the cost savings of an HMO plan and the flexibility of a PPO plan. In a POS plan, a primary care doctor acts as a gatekeeper and refers patients to other providers in the plan, but members can refer themselves outside the plan and still get some coverage. If the doctor refers out of the network, the plan pays all or most of the bill. If POS members self-refer to doctors or specialists outside the network, they will have to pay a predetermined amount of co-insurance. Generally, in a POS plan, the level of co-payments and co-insurance will rise based on the choices made by the member. PPO (Preferred Provider Organization) A PPO is an organization or group that has arrangements with doctors, hospitals and other healthcare providers that have agreed to accept lower fees from the insurer for their services. As a result, cost sharing is lower for plan members within a PPO network. Network healthcare providers make referrals, but plan members can self-refer to doctors and specialists, including those outside the plan. A PPO plan allows you to choose any doctor at any time. However, if you seek services from a non-network provider you will have more out-of-pocket expenses than if a PPO provider was utilized. Premium The premium is the total amount paid to the insurance company for the benefits provided under the health plan. Typically a monthly charge, the group premium is paid in whole or in part by the employer on behalf of the employees or the employee's dependents for health insurance coverage. Primary Care Physician Under a health maintenance organization (HMO) or point-of-service (POS) plan, a primary care physician is usually the first contact for health care. This is often a family physician, internist, or pediatrician. A primary care physician makes referrals to specialists if necessary. Standard Industrial Classification (SIC) Codes The Standard Industrial Classification is a statistical classification that covers the entire field of economic activities and defines industries in accordance with the composition and structure of the economy. |
|
About Us ·
Group Quotes ·
Individual Quotes ·
Customer Service
Industry Links · Glossary of Terms · Things to Consider · Ask Robbi Frequently Asked Questions · Privacy Policy · Disclaimer · Contact Us · Home |
|
|
|