The amount you are required to pay for
medical care in a fee-for-service plan or preferred provider organization (PPO) after you
have met your deductible. 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.
- Copayment
A specific charge you pay for a specific
medical service. For example, you may pay $10 for an office visit or $5 for a prescription
and the health plan covers the rest of the medical charges.
- Deductible
The amount of money you must pay each year
to cover your medical care expenses before your insurance policy starts paying.
- Exclusions
Exclusions are specific conditions or
circumstances for which the policy will not provide benefits.
- Fee-for-Service
A payment system for health care where the
provider is paid for each service rendered rather than a pre-negotiated amount for each
patient.
- HMO (Health Maintenance Organization)
Prepaid health plans in which you pay a
monthly premium and the HMO covers your cost of care to see doctors within their network
at pre-negotiated rates. You must choose a primary care physician who coordinates all of
your care and makes referrals to any specialists you might need. 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.
- IPA (Independent Practice Association)
An independent group of physicians who
contract with an HMO to provide services for the HMO members. Some health insurance
applications will ask for a physician's IPA number. It can usually be found in an online
provider directory for the health plan or by calling the physician's office.
- 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.
- MSA (Medical 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 copayments.
- Out-of-Pocket Maximum
The most money you will be required to pay
in a year for deductibles and coinsurance in addition to regular premiums.
- Point-of-Service (POS) Plan
A type of managed care plan combining
features of health maintenance organizations (HMOs) and preferred provider organizations
(PPOs). You can decide whether to go to a network provider and pay a flat dollar or to an
out-of-network provider and pay a deductible and/or a coinsurance charge.
- Pre-existing Condition
A health problem that existed or was
treated before the date your insurance became effective. Most health insurance contacts
have a pre-existing condition clause that describes under what conditions they will cover
medical expenses related to a pre-existing condition.
- PPO (Preferred Provider Organization)
A network of health care providers that
have agreed to provide medical services to a health plan's members at discounted costs.
PPO members typically make their own decisions about their health care rather than going
through a primary care physician like HMO member. The cost to use physicians within the
PPO network is less than using a non-network provider.
- Premium
The amount you pay in exchange 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.
- Provider
Any person (doctor or nurse) or
institution (hospital, clinic, or laboratory) that provides medical care.
- Well-Baby
Preventative health services, including
immunizations, provided by the member's participating medical group up to a specific age
specified by the carrier. This benefit is typically provided in HMO plans and/or POS
plans. The level of benefit will vary for PPO plans if specified as a benefit.
