ZINTAX CONSULTING
Glossary Medical Insurance
Allowed Amount
This is the maximum payment the plan will make for a covered healthcare service. It may also be called "eligible expense," "payment allowance," or "negotiated rate."
Claim
A request for a benefit (including reimbursement of a health care expense) made by you or your health care provider to your health insurer or plan for items or services you think are covered.
Coinsurance
Coinsurance is a cost-sharing arrangement in health insurance where the insured individual is responsible for a percentage of covered medical expenses after meeting the deductible. After the deductible is satisfied, the insurance company and the insured share the costs of covered services according to the coinsurance percentage. For example, if the coinsurance is 20% and the medical service costs $1,000, the insured would pay $200 (20% of $1,000) while the insurance company would cover the remaining $800. Coinsurance helps individuals share the financial responsibility of healthcare expenses with the insurance company and can vary based on the specific health insurance plan and the services received.
Copay
A copay is a fixed out-of-pocket amount an insured pays for covered services. It is a standard part of many health insurance plans. Insurance providers often charge co-pays for services such as doctor visits or prescription drugs.
Cost Sharing
Your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called “out-of-pocket costs”). Some examples of cost-sharing are copayments, deductibles, and coinsurance. Family cost sharing is the share of the cost for deductibles and out-of-pocket costs you and your spouse and/or child must pay out of your own pocket. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan doesn’t cover, usually aren't considered cost-sharing.
Deductible
Deductible is a term you might have heard about your health insurance costs. But what exactly is a deductible? Here is what it means: Your annual deductible is typically the amount of money you, as a member, pay out of pocket each year for allowed amounts for covered medical care before your health plan begins to pay. This excludes certain preventive services that may be automatically covered. Deductibles can be high or low, depending on your project, which may affect how you pay for health care costs.
What is an embedded deductible?
The first is an embedded deductible, meaning that there are two deductible amounts within one plan: single and family. The single deductible is embedded in the family deductible, so no one family member can contribute more than a single amount toward the family deductible.
Diagnostic Test
Tests to figure out what your health problem is. For example, an x-ray can be a diagnostic test to see if you have a broken bone.
Embedded Deductible
An embedded deductible is where each family member has an individual deductible in addition to the overall family deductible. When a family member meets his or her deductible before the family deductible is reached, the insurance company will begin paying according to the plan’s coverage for that member. If only one family member meets an individual deductible, the rest of the family still has to pay their deductibles. Out-of-pocket expenses used to meet a separate deductible are counted toward meeting the family deductible, which is usually twice as large as an individual deductible. However, after an individual completes his or her deductible, coinsurance or copays typically will not count toward the family deductible. Once the family deductible is met, all family members will have medical expenses paid according to the plan’s coverage, even if they have not met their deductibles. The POS 1000, POS 750, and the OOA POS 750 have an embedded deductible. Embedded Deductible Example: The Lee family has the POS 1000 plan that covers Mr. and Mrs. Lee and their two children. Each family member has a $1,000 individual deductible, and they have a $2,000 family deductible. Mr. Lee met his $1,000 deductible after attending the emergency room in February. Mrs. Lee had an outpatient surgery and met her $1,000 individual deductible in March, which means the family deductible of $2,000 has now been met. The insurance company will cover any further medical care for anyone in the family according to the plan benefits.
Emergency Medical Condition
An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you do not get medical attention right away. If you did not get immediate medical attention, you could reasonably expect one of the following: 1) Your health would be put in serious danger, or 2) You would have serious problems with your bodily functions, or 3) You would have serious damage to any part or organ of your body.
Emergency Medical Transportation
Ambulance services for an emergency medical condition. Types of emergency medical transportation may include air, land, or sea. Your plan may not cover all emergency medical transportation or pay less for certain types.
Emergency Room Care / Emergency Services
Services to check for an emergency medical condition and treat you to keep an emergency medical condition from getting worse. These services may be provided in a licensed hospital’s emergency room or other place that provides care for emergency medical conditions.
Excluded Services
Health care services that your plan does not pay for or cover.
Formulary
A formulary is a list of drugs your plan covers. It may include how much your share of the cost is for each drug. Your plan may put drugs in different cost-sharing levels or tiers. For example, a formulary may include generic and brand-name drug tiers and different cost-sharing amounts will be applied to each tier.
Habilitation Services
Health care services help a person learn or improve skills and functioning for daily living. Examples include therapy for a child not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in various inpatient and/or outpatient settings.
Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. Some plans may consider an overnight stay for observation as outpatient care instead of inpatient care.
Hospital Outpatient Care
Care in a hospital that usually does not require an overnight stay.
In-network Coinsurance
Your share (for example, 20%) of the allowed amount for covered health care services. Your share is usually lower for in-network covered services.
In-network Copayment
You pay a fixed amount (for example, $15) for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.
Maximum Out-of-pocket Limit
The federal government sets a yearly amount that each individual or family can be required to pay in cost sharing during the plan year for covered, in-network services. This amount applies to most types of health plans and insurance. It may be higher than the out-of-pocket limits stated for your plan.
Network Provider (Preferred Provider)
A provider with a contract with a health insurer or plan has agreed to provide services to plan members. You will pay less if you see a provider in the network, which is also called “preferred provider” or “participating provider.”
Out-of-network Coinsurance
Your share (for example, 40%) of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
Out-of-network Copayment
You pay a fixed amount (for example, $30) for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network copayments are usually higher than in-network copayments.
Out-of-network Provider (Non-Preferred Provider)
A provider who does not have a contract with your plan to provide services. If your plan covers out-of-network services, you will usually pay more to see an out-of-network provider than a. Your policy will explain what those costs may be. It may also be called “non-preferred” or “non-participating” instead of “out-of-network provider”.
Out-of-pocket Limit
The most you could pay during a coverage period (usually one year) is your share of the costs of covered services. After you meet this limit, the plan will usually pay 100% of the amount allowed. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges, or health care your plan does not cover. Some plans do not count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. See a detailed example.
Physician Services
Health care services a licensed medical physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), provides or coordinates.
Plan
Health coverage issued to you directly (individual plan) or through an employer, union, or other group sponsor (employer group plan) that provides coverage for certain health care costs is also called a "health insurance plan," "policy," "health insurance policy," or "health insurance."
Preauthorization
Preauthorization is a decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment (DME) is medically necessary. It is sometimes called prior authorization, prior approval, or precertification. Your health insurance or plan may require preauthorization services before you receive them, except in an emergency. Preauthorization does not guarantee that your health insurance or plan will cover the cost.
Prescription Drugs
Drugs and medications that, by law, require a prescription.
Preventive Care (Preventive Service)
Routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems.
Primary Care Physician
A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), who provides or coordinates a range of healthcare services for you.
Primary Care Provider
A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law and the terms of the plan, who provides, coordinates, or helps you access a range of health care services.
Provider
An individual or facility that provides health care services. Some examples of providers include a doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, and rehabilitation center. The plan may require the provider to be licensed, certified, or accredited, as state law requires.
Referral
A written order from your primary care provider to see a specialist or get certain health care services. In many health maintenance organizations (HMOs), you need a referral before you can get health care services from anyone except your primary care provider. The plan may not pay for the services if you do not get a referral.
Specialist
A provider focuses on a specific area of medicine or groups of patients to diagnose, manage, prevent, or treat certain symptoms and conditions.
UCR (Usual, Customary, and Reasonable)
The amount paid for a medical service in a geographic area is based on what providers in the area usually charge for the same or similar medical service. The UCR amount is sometimes used to determine the allowed amount.
Urgent Care
Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away but not so severe as to require emergency room care.
