| COBRA |
Federal legislation that requires employers with 20 or more
employees to offer employees (and/or dependents) to continue
coverage under the group plan for eighteen to 36 months. More
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| Co-Insurance |
The percentage of covered expenses an insured individual shares
with the carrier. (i.e., for an 80/20 plan, the health plan
member's co-insurance is 20%.) If applicable, co-insurance applies
after the insured pays the deductible and is only required up to
the plan's stop loss amount. (see "stop loss.") |
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| Co-pay/Co-payment |
The amount an insured individual must pay toward the cost of a
particular benefit. For example, a plan might require a $10 co-pay
for each doctor's office visit. |
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| Deductible |
Amount of covered expenses that must be paid by subscriber
before coverage begin. Unless otherwise noted, deductibles are on
a calendar year basis.
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| HIPAA |
Federal legislation requiring all insurers who offer individual
coverage to provide their two most popular plans on a guaranteed
acceptance basis to all applicants whose group coverage (including
COBRA) ended within 63 days prior to application for coverage.More
info |
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| Health Maintenance Organization (HMO) |
An alternative to commercial insurance that stresses preventive
care, early diagnosis and treatment on an outpatient basis. HMOs
are licensed by the state to provide care for enrollees by
contracting with specific health care providers to provide
specified benefits. Many HMOs require enrollees to see a
particular primary care physician (PCP) who will refer them to a
specialist if deemed necessary. |
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| Network |
A group of doctors, hospitals and other providers contracted to
provide services to insured individuals for less than their usual
fees. Provider networks can cover large geographic markets and/or
a wide range of health care services. If a health plan uses a
preferred provider network, insured individuals typically pay less
for using a network provider. |
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| Out-of-Network |
describes a provider or health care facility which is not part
of a health plan's network. Insured individuals usually pay more
when using an out-of-network provider, if the plan uses a network. |
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| Out of pocket maximum |
The amount of expenses incurred by an individual at which the
plan pays 100% of covered expenses. Amounts in excess of scheduled
allowances and other non-covered expenses do not count toward the
out of pocket maximum. Family out of pocket maximums can be
aggregate (the total expenses by all family members added
together) or separate (a certain number of family members must
reach their individual out of pocket maximum to initiate the
benefit). Quotes display family aggregate out of pocket maximums
as a fixed dollar amount and separate out of pocket maximums as
the number of out of pocket maximums required per family.
Deductibles are included in the out of pocket maximum.
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| Preferred Provider Organization (PPO) |
A network or panel of physicians and hospitals that agrees to
discount its normal fees in exchange for a high volume of
patients. The insured individual can choose from among the
physicians on the panel. |
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| Schedule of allowable charges |
Pre-determined amount the carrier will pay for services provided
by non-contracted provider. Generally carriers set the allowable
fee schedule at the same level as the negotiated rate for
contracting providers. Since there is no contractual obligation on
the part of non-contracting providers to accept the fee schedule,
the customer is responsible for all charges in excess of the
schedule. |
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| Short-term medical |
Temporary health coverage for an individual for a short period
of time, usually from 30 days to six months. |
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| Stop-loss |
The dollar amount of claims filed for eligible expenses at which
the insurance begins to pay at 100% per insured individual.
Stop-loss is reached when an insured individual has paid the
deductible and reached the out-of-pocket maximum amount of
co-insurance. |
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| UCR |
Short for usual, reasonable and customary, which is a method
that some carriers use to determine allowable charges for
non-contracted providers. Usual means the charge that a given
provider usually charges, reasonable takes into account
extenuating circumstances, customary means what is generally
charged in the geographic area. Different carriers have various
methods of calculating UCR. |