| Co-insurance: |
Co-insurance
refers to money that an individual is required to pay for
services, after a deductible has been paid. In some health
plans, coinsurance is called a "copayment." Co-insurance
is often specified by a percentage. For example, the employee
pays 20% toward the charges for a service and the employer
or insurance company pays 80%. |
| Copayment: |
Co-payment
is a predetermined fee that an individual pays for health
care services, in addition to what the insurance covers.
For example, some HMOs require a $10 "co-payment" for each
office visit, regardless of the type or level of services
provided during the visit. Co-payments are not usually specified
by percentages. |
| Deductible:
|
The
amount an individual must pay for health care services before
insurance covers any of the costs. Deductibles are most
frequently charged on an annual basis rather than on a per
incident basis. |
| Health
Maintenance Organizations (HMOs): |
Health
Maintenance Organizations represent "pre-paid" or "capitated"
health care plans in which individuals pay small fees or
copayments for specified health care services over and above
the monthly premiums paid to be a member of the HMO. Services
are provided by physicians and allied health care personnel
who are employed by, or under contract with the HMO. HMOs
vary in design. Depending on the type of HMO, services may
be provided in a central facility, or in an individual
physicians office. HMO's are available on both an individual
and employer group basis. |
| Long
Term Care Policy: |
Insurance
policies that cover the costs of providing nursing care,
home health care services and custodial care for the aged
and infirmed. |
| Lifetime
Maximum Payment: |
The
maximum amount of money that an insurance company will pay
for claims within a specific period of time. For instance,
most PPO types of programs have an overall lifetime maximum
expressed in millions of dollars (usually a minimum of $1M).
Maximum dollar limits vary greatly. They may be based on
the type of illness or expressed in a period of time. |
| Medigap
Insurance Policies: |
Medigap
insurance is offered by private insurance companies, not
the government. It is not the same as Medicare or Medicaid.
These policies are designed to pay for some of the costs
that Medicare does not cover. |
| Out-Of-Pocket
Maximum: |
A
predetermined limited amount of money that an individual
must pay out of pocket, before an insurance company will
pay 100% for an individual's health care expenses. |
| Pre-Existing
Medical Conditions: |
Any
illness or health problem that existed prior to an individual
obtaining medical coverage. Group health plans will cover
pre-existing conditions after you have been covered for
at least six months; individual plans after 12 months. |
| Primary
Care Provider (PCP): |
A
health care professional who is responsible for monitoring
an individual's overall health care needs. Typically, a
PCP serves as a "gatekeeper" for an individual's medical
care, referring the individual to specialists and admitting
them to hospitals when needed. |
| Reasonable
and Customary Charges: |
The
charges that a carrier determines normal for a particular
medical procedure in a specific geographic area. If charges
are higher than what the carrier considers normal, the
carrier will not pay the full amount charges and the balance
is the responsibility of the insured. |
| Waiting
Period: |
A period of time when you are
not covered by insurance for a particular medical problem.
|