Annual
Deductible — The
amount you pay for covered expenses first, before
an insurance plan begins to pay benefits. Some
plans require deductibles for all services, some
for just
certain types of services; others require no
deductible at all.
back to top
Co-Pay/Co-Insurance — The
flat amount or percentage you pay for a covered service
after you satisfy the annual deductible, if applicable.
back to top
Covered
Expenses — Charges for services that are
medically necessary and eligible for payment under
the plan contract.
back to top
Emergency — A
sudden, unexpected or serious acute illness, injury
or condition which could permanently endanger your health
if medical treatment is not received immediately.
back to top
HMO
(Health Maintenance Organization) — An
organization that provides a wide range of comprehensive
health
care services through a designated group, network
of doctors, hospital or lab. To receive benefits,
you
must see the doctor you select as your Primary
Care Physician (PCP) first for care or a referral,
except
in the case of an emergency. Your choice of doctors
is restricted to those in the network.
back to top
IPA
(Independent Physicians Association) — Primary
Care Physicians who practice in his/her own office,
but are part of a larger network of physicians.
back to top
Individual
Insurance — Health care coverage for individuals
or single family units.
back to top
Limited
Fee Schedule — A list of maximum amounts
the insurance carrier will pay for certain services
provided
by non-network providers. You are responsible for
paying your co-insurance and any amount over the
limited fee
schedule.
back to top
Network/In-Network — The
term used for services received from doctors, hospitals
and other providers contracted with the carrier to
provide care at the negotiated fee and to handle the
paperwork.
back to top
Out-of-Network/Non-Network — The
term used for services received from doctors, hospitals
or other providers that are not part of the network.
You pay substantially more for Out-of-Network services.
back to top
Out-of-Pocket
Maximum — The most you pay for covered
expenses during the year before the plan begins
paying 100%
of covered expenses for the rest 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.
back to top
PCP
(Primary Care Physician) — The doctor
who serves as your health care manager and coordinates
virtually all of the health care services you receive.
Your PCP provides you with routine medical care
and
refers you to a specialist if necessary.
back to top
PMG
(Participating Medical Group) — A group
of doctors, both primary care physicians and specialists,
who are practicing in one location to provide health
care services. Most medical services, including
special
exams, x-ray and laboratory tests are available
in one convenient location.
back to top
PPO
(Preferred Provider Organization) — Health
care providers who are under contract to provide care
at discounted or fixed fees. Unlike HMOs, health plans
with a PPO allow you to choose any doctor at any time.
However, if you select a non-PPO provider you will
pay more out of pocket for services than you would
if you selected a PPO "network" provider.
back to top
Pre-existing
Condition/Pre-existing Waiting Period — An
illness, disease or physical condition for which medical
advise, diagnosis, care or treatment was recommended
or received from a licensed health practitioner during
the six months prior to the effective date of a person’s
new medical coverage or plan.
back to top
Qualifying
Prior Coverage — Any individual or group
plan that provides medical, hospital, and surgical
coverage,
including continuation or conversion coverage or
coverage under a publicly sponsored program such
as Medicare
or Medicaid. It does not include accident only,
credit, disability income, Medicare supplement,
long term care
insurance, dental, vision, workers' compensation
insurance, automobile insurance, no-fault insurance,
or any medical
coverage designed to supplement other private or
governmental plans.
back to top
Specialist — A
physician whose practice is limited to a particular
branch of medicine or surgery.
back to top
