Case Management
- A technique that insurance companies and HMOs use to ensure that
individuals receive appropriate, timely, and reasonable health care services.
Claim
- A request by an individual (or his/her provider) for the insurance
company to pay for services obtained.
Coinsurance
- The money that an individual is required to pay for services, after
a deductible has been paid. In some health plans, coinsurance is
referred to as "copayment." It is often a specified
percentage of the charges. For example, the employee pays 20% of the
charges while the health plan pays 80%.
Copayment
- An arrangement where an individual pays a specified amount for
various health care services and the health plan or insurance company
pays the remainder. The individual must usually pay his or her share
when services are rendered. The concept is similar to coinsurance,
except that copayments are usually a set dollar amount (such as $20
per office visit), rather than a percentage of the charges.
Deductible
- A set dollar amount that a person must pay before insurance
coverage for medical expenses can begin. They are usually charged on
an annual basis.
Denial of Claim
- Refusal by an insurance company to pay a submitted request for
health care services obtained.
Employee
Assistance Program (EAP)
- Mental health counseling services that are sometimes offered by
insurance companies or employers. Typically, individuals or employers
do not have to pay directly for EAP services provided.
Exclusions
and Limitations
- Specific conditions or circumstances for which an insurance policy
or plan will not provide coverage (exclusions), or for which coverage
is specifically limited (limitations.)
Health
Maintenance Organization (HMO)
- Prepaid, or capitated, health care plans in which individuals pay a
small monthly fee to be a member of the HMO, as well as small fees or
copayments for specified health care services. Services are provided
by physicians and allied health care personnel who are employed by or
under contract with the HMO. HMOs are available to both individuals
and employer groups.
Indemnity Plans
- Also known as "fee-for-service" plans. These existed
primarily before the rise of HMOs and PPOs. The individual pays a
predetermined percentage of the cost of health care services, and the
insurance company (or self-insured employer) pays the other remaining
charges. Fees for services are determined by individual providers,
and therefore vary from physician to physician. Indemnity health
plans allow individuals to choose their own health care professionals
- there are no provider networks from which to choose.
Independent
Practice Association (IPA)
- A group of independent practicing physicians who band together for
the purpose of contracting with HMOs, PPOs, and insurance companies
for their services.
In-Network
- Typically refers to physicians, hospitals, or other health care
providers who contract with the insurance plan (usually an HMO or
PPO) to provide services to its members. Coverage for services
received from in-network providers will typically be greater than for
services received from out-of-network providers, depending on the plan.
Long-term
Care Insurance -
Insurance policies that cover the costs of providing nursing care,
home health care services, and custodial care for the aged and infirm.
Managed Care
- A system of health care delivery that is characterized by
arrangements with selected providers, ongoing quality control and
utilization review programs, and financial incentives for members to
use providers and procedures covered by the plan.
Maximum Benefit
- The maximum dollar amount that an insurance company will pay for
claims, either for a specific service or procedure, or during a
specified period of time.
Medically Necessary
- A term used to describe the supplies and services needed to
diagnose and treat a medical condition in accordance with the
standards of good medical practice. Many health plans will only pay
for treatment deemed medically necessary. For example, most plans
will not cover elective cosmetic surgery.
Out-of-Network
- Typically refers to physicians, hospitals, or other health care
providers who do not contract with the insurance plan (usually an HMO
or PPO) to provide services to its members. Depending upon the
insurance plan, expenses incurred for services provided by
out-of-network providers might not be covered, or coverage may be
less than for in-network providers.
Out-of-Pocket
Maximum - The
total amount paid each year by the member for the deductible and
coinsurance. After reaching the out-of-pocket maximum, the plan pays
100% of the allowable charges for covered services the rest of that
calendar year.
Point-of-Service
Plan (POS) - A
type of HMO that allows the patient to see either in-network or
out-of-network providers. However, the patient pays more out of
pocket when using an out-of-network provider.
Pre-admission
Certification -
Also called "precertification" or "pre-admission
review." Approval granted by a case manager or insurance company
representative (usually a nurse) for a person to be admitted to a
hospital or inpatient facility before admittance. The goal is to
ensure that individuals are not exposed to inappropriate health care
services, or services that are not medically necessary.
Pre-existing
Condition - Any
medical condition that was diagnosed or treated within a specified
period immediately before a health insurance policy became effective.
These conditions may not be covered for a specified period of time
under the new policy.
Preferred
Provider Organization (PPO)
- A type of managed care plan in which doctors and hospitals agree to
provide discounted rates to plan members. Patients are typically
reimbursed 80-100% for treatment received within the network, versus
50-70% outside the network.
Primary
Care Physician (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 him or her to
specialists and admitting him or her to hospitals when needed.
Reasonable
and Customary Charges
- The commonly charged or prevailing fees for health services within
a geographic area. If charges are higher than what an insurance
carrier considers reasonable and customary, the carrier will not pay
the full amount and instead will pay what is deemed appropriate for
the particular service. The remaining charges then are the
responsibility of the patient.
Self-Insured
- A health benefits plan in which the employer is at risk for the
cost of its employees' health care. Typically, a third party provides
administrative services for the plan to the employer group.
Waiting Period
- A period of time in which your health plan does not provide
coverage for a particular pre-existing condition.
Waiver
- A rider or amendment to a policy that restricts benefits by
excluding certain medical conditions from coverage.
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