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Notes Insurance Noval

The document provides definitions and explanations of various health insurance terms, including coinsurance, premium, exclusions, and types of plans such as HMO, PPO, and Medicare. It also covers concepts like deductibles, out-of-pocket maximums, and health savings accounts. Overall, it serves as a comprehensive glossary for understanding health insurance terminology.

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0% found this document useful (0 votes)
14 views3 pages

Notes Insurance Noval

The document provides definitions and explanations of various health insurance terms, including coinsurance, premium, exclusions, and types of plans such as HMO, PPO, and Medicare. It also covers concepts like deductibles, out-of-pocket maximums, and health savings accounts. Overall, it serves as a comprehensive glossary for understanding health insurance terminology.

Uploaded by

Eunice Noval
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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 Coinsurance

The percentage of the costs of a covered health care service or prescription drug you pay
after you've paid your deductible.
 Premium
what you'll pay the insurance company for the privilege of having an active insurance plan.
 Exclusions
Specific medical conditions or circumstances that are not covered under a health plan.
 HMO
A health maintenance organization (HMO) plan might give you the least amount of flexibility
in terms of who you can choose as a provider.
 Inpatient
Services are provided when a member is registered as a bed patient in a health care facility,
such as a hospital.
 Benefit
the amount payable by the insurance company to a plan member for medical costs.
 Group Health Insurance
plans that cover several members of an organization are called group health insurance
plans.
 Network
A group of healthcare providers and facilities participating in a health insurance plan.
 Deductible
is what you pay annually for health services before your insurance company pays its share.
 Claim
An itemized bill from a health care provider, for health services provided to a member.
 Out-of-pocket maximum
The most money you will be required to pay each year for deductibles and coinsurance.
 Provider
 Pre-existing condition
A medical condition was determined to have been in existence before the policy went into
effect.
 Dependent
e amount of money you must pay each year to cover eligible medical expenses before your
insurance policy starts paying.
 High deductible health plan
High Deductible Health Plan (HDHP) A high-deductible health plan (HDHP) is a type of
insurance plan with a higher deductible than traditional insurance
 Preferred provider
A provider who has a contract with your health insurer or plan who has agreed to provide
services to members of a plan.
 Copayment
The copayment (or copay) is the amount you owe each time you receive certain types of
medical care.
 Coordination of benefits
a system used in group health plans to eliminate duplication of benefits when you are
covered under more than one group plan.
 Health Savings Account (HSA)
An account set up with your bank or employer that allows you to save pretax money
throughout the year to cover qualifying out
 Allowable charge
 Allowed amount
The charge amount that an insurer agrees is reasonable for a service or procedure.
 Essential health benefits
The ACA-required healthcare services must be covered by plans offered in the health
insurance marketplace and states
 Insured
The person who a contract holder (an employer or insurer) has agreed to provide coverage
for, often referred to as a member/subscriber.
 Benefit Level
the maximum amount that a health insurance company has agreed to pay for a covered
benefit.
 Benefit year
the 12-month period for which health insurance benefits are calculated, not necessarily
coinciding with the calendar year. Health insurance companies may update plan benefits and
rates at the beginning of the benefit year.
 Effective date
the date on which a policyholder's coverage begins.
 Health Maintenance Organization (HMO) plan
a health care financing and delivery system that provides comprehensive health care
services for enrollees in a particular geographic area. HMOs require the use of specific, in-
network plan providers.
 In-network provider
a health care professional, hospital, or pharmacy that is part of a health plan’s network of
preferred providers. You will generally pay less for services received from in-network
providers because they have negotiated a discount for their services in exchange for the
insurance company sending more patients their way.
 Individual health insurance
health insurance plans purchased by individuals to cover themselves and their families.
Different from group plans, which are offered by employers to cover all of their employees.
 Medicaid
a health insurance program created in 1965 that provides health benefits to low-
income individuals who cannot afford Medicare or other commercial plans.
Medicaid is funded by the federal and state governments and managed by the
states.
 Medicare
the federal health insurance program that provides health benefits to Americans aged 65 and
older. Signed into law on July 30, 1965, the program was first available to beneficiaries on
July 1, 1966, and later expanded to include disabled people under 65 and people with
certain medical conditions. Medicare has two parts; Part A, which covers hospital services,
and Part B, which covers doctor services.
 Medicare Supplement plans
plans offered by private insurance companies to help fill the "gaps" in Medicare coverage.
 Out-of-network provider
a health care professional, hospital, or pharmacy that is not part of a health plan's network of
providers. You will generally pay more for services received from out-of-network providers.
 Payer
the health insurance company whose plan pays to help cover the cost of your care. Also
known as a carrier.
 Point-of-Service (POS) plan
A type of managed care plan that allows customers to use out-of-network providers but at an
additional cost (usually a higher coinsurance and/or deductible). You receive the highest
level of benefits from in-network providers.
 Preferred Provider Organization (PPO) plan
a health insurance plan that offers greater freedom of choice than HMO (health
maintenance organization) plans. Customers with PPOs are free to receive care
from both in-network or out-of-network (non-preferred) providers but will receive
the highest level of benefits when they use providers inside the network.
 Premium the amount you or your employer pays each month in exchange for
insurance coverage.
 Waiting period
The period of time that an employer makes a new employee wait before he or
she becomes eligible for coverage under the company's health plan. Also, the
period of time beginning with a policy's effective date during which a health plan
may not pay benefits for certain pre-existing conditions.

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