Personal medical insurance
Read through and become conversant with these definitions to enable
you to communicate intelligently about your personal medical insurance
with insurance professionals and medical providers.
Admitting Privileges - The ability of a doctor to admit a patient
to a particular hospital.
Assignment of Benefits - When you assign benefits,
you sign a document allowing your hospital or doctor to collect your
personal medical insurance benefits directly from your health carrier.
Otherwise, you pay for the treatment and then the company reimburses
you.
Capitation - Capitation represents a set
dollar limit that your health maintanence organization (HMO) pays to your primary care physician for providing medical treatment to you and your dependents. This fee is usually paid to the physician on a monthly basis. The physician gets no more nor no less than this set fee no matter how much you use his or her services.
Case Management - Case management
is a system that insurance companies and HMO's use to ensure that individuals receive appropriate, timely, and reasonable health care services.
Claim - A request by an individual ( or his or her health
care provider) to an individual's personal medical insurance company
for the insurance company to pay for services obtained from a
health care professional.
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 personal medical 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.
Denial of a Claim - Refusal by an insurance company to pay
a claim submitted to them on behalf of an insured individual by a health
care provider.
Exclusions and Limitations - Medical
services that are either not covered or limited in benefit by an individual's insurance policy.
Guaranteed Issue - An insurance company or HMO will issue coverage
to an applicant regardless of prior medical history. In personal
medical insurance, small employers (defined as 3 to 50 employees) cannot
be refused coverage for their employees regardless of the medical
history of one or more employees.
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.
Indemnity Health Plan - Indemnity health insurance plans
are also called "fee-for-service." These are the types
of plans that primarily existed before the rise of HMOs, IPAs and PPOs.
With indemnity plans, the individual pays a predetermined percentage
of the cost of health care services, and the personal medical
insurance company pays the additional percentage ultimately adding
up to 100% of charges. For example, an individual might pay 20%
for services and the insurance company pays 80%. The fees for services
are defined by the providers and vary from physician to physician.
Indemnity health plans offer individuals the freedom to choose
any physician or hospital.
Independent Practice Associations - A
group of independent practicing physicians who band together for the purpose of contracting their services to HMOs, PPOs and insurance companies.
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.
Managed Care - The system that HMOs,
PPOs and indemnity plan uses to provide quality health care while controlling the costs of medical services that individuals receive.
Maximum Dollar Limit - 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.
Medically Necessary - Many insurance
policies will pay only for treatment that is deemed "medically necessary" to restore a persons health. For instance, many policies will not cover routine physical exams or plastic surgery for cosmetic purposes.
Medigap Insurance Policies - These personal medical insurance
policies are designed to pay for some of the long term care costs that
Medicare does not cover. .
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.
Preferred Provider Organizations (PPOs) - This is a group of health care providers who have agreed by
contract to furnish medical services to members of a health plan at discounted rates.
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.
Click here for a Free
Insurance Rate Quote.
|
CompareInsure