Glossary Of Terms

Accident and Health Insurance: Insurance under which benefits are payable in case of disease and accidental injury. Also known as health insurance,individual family plan, personal health insurance,high deductible health plan, sickness and accident insurance.

Application: Form supplied by the insurance company, usually filled out by the insurance agent on the basis of information collected by the applicant. It is signed by the applicant and is part of the insurance policy.

Obama Care: builds on the current health care system and provides easy access to health coverage, guaranteed coverage for all Americans, and affordable coverage for most individuals.

Subsidy or tax credit: When the government pays for all or a fraction of your health insurance premium, due low to moderate income.

Marketplace: This is an online insurance exchange that offers individuals and small businesses a choice of health plans that meet certain benefits and cost standards.

Open Enrollment: The period of time set up to allow individuals to choose from available plans, usually once a year. Open enrollment will start October 1st, 2013 –March 31, 2014.

Maternity plans: Having a child is a true blessing but unfortunately there is a financial burden associated with having them. I’m not talking about diapers, milk, formula, or an iPod, a car, or even college (the list really never ends). The cost of actually having the baby can be expensive. The list really begins with doctor visits, prenatal care, ultrasounds, and a hospital visit.All plans effective after January 1, 2014 will have Maternity coverage. There will not be additional costs for this coverage.

Since having a child is so important, it is recommended to call and work with an agent closely and choose the right plan with confidence – (866) 396-9140

Best’s Insurance Report: A guide, published by A.M. Best Inc. that rates insurers’ financial integrity and managerial and operational strengths.

Broker: Licensed insurance representative who does not represent a specific insurance company, but places insurance policy among various insurance carriers. Legally, the broker is usually regarding as representative of the insured rather than the company.

Catastrophic Heath Care Insurance: Health Insurance policy that provides broad coverage and high benefits for hospitalization and surgical procedures.
COBRA: Consolidated Omnibus Budget Reconciliation Act of 1985, extending group health insurance coverage to terminated employees and their families for up to 18 months.

Coinsurance: Also known as percentage participation, principle under which the company insures only part of the potential loss and the policy owner paying the other part. For instance, with a high deductible health plan, the company may pay 75 percent of the insured expenses, with the insured to pay the other 25 percent. Usually there is cap or maximum that you would pay and is expressed in the “out of pocket maximum”.

Deductible: Amount of expense or loss to be paid by the insured before a health insurance policy starts paying benefits. Individual family plan may offer some benefits that a deductible is not required such as preventive care or doctor visit co pays. Be sure to ask your health insurance agent how your deductible works.

Discount Health Care Insurance: Also known as limited benefit insurance or indemnity insurance. A plan that pays benefits to insureds based on a predetermined, fixed rate set for the medical services provided, regardless of the actual expense incurred.

Free Look: Provision required in most states whereby policyholders have either 10 or 20 days to examine their new policies at no obligation.

Grace Period: Period of time after the payment due date during which the policy remains in force without penalty.

Group / Employer Insurance – insurance offered at the workplace with the employer contributing a portion of the health insurance premiums. These plans are generally not underwritten. Employment is the only stipulation for receiving coverage. The employee’s spouse and/or children can be added to the policy for additional health premiums

Health Insurance Portability and Accountability Act (HIPAA) – Extensive law relating to many aspects of health care, but as far as insurance goes, it provides insurance on a guaranteed basis, when someone who has had creditable coverage for more than 24 months (without more than a 63 day gap) when that person has no other options (Ex. – exhausted COBRA extension, insurance company or employer of workplace goes out of business, etc.)

Health Saving Account (HSA): An HSA is a tax favored saving account which allows funds to be accumulated tax free to pay for current and future qualified health care expenses. The Medicare Prescription Drug Improvement and Modernization Act of 2003 made HSA’s possible. You must have a HSA compatible health plan in order to take advantage of the account’s benefits.

HMO: Health Maintenance Organization is a specific health care plan that sets out guidelines under which doctors can operate. HMO’s usually restricts which procedures can be conducted and often need referrals from primary doctors in order to see a specialist.

Individual / Family Plan – a plan that is purchased and applied for by an individual for their self or family and not obtained from their employer or workplace. These plans generally are underwritten and have much more options than group coverage. You can also keep you policy as long as you need regardless of your employment situation.

Insurer: Party that provides insurance coverage, typically through a contract of insurance.

Provider Network: A group of medical service providers that consists of hospitals, doctors, clinics, and laboratories. These medical providers have established contracts with the insurance carriers.

PPO: Preferred Provider Organization is an association of health care providers, such as doctors and hospitals, which agree to provide health care to members of a particular group at fees negotiated in advance.

Preexisting condition: An illness or medical condition that existed before a policy’s effective date; usually excluded from coverage, through the policy’s standard provision or by an exclusionary waiver or rider depending on the health condition.

Health Insurance Premiums: The periodic payment required to keep an insurance policy into effect. Health insurance premiums are usually paid monthly, quarterly, semi annually or annually.

Medicare Advantage planalso referred to as Medicare Part C, is an insurance plan offered by a private insurance carrier and becomes your primary health plan. Usually prescription coverage is included with the plan. Must still be enrolled in Medicare Part A & Part B. Medicare Advantage plans are almost always more affordable compared to supplements.

Medicare Part A – part of Medicare that covers hospitalization after any applicable deductibles, coinsurances, and copayments

Medicare Part B – part of Medicare that covers outpatient procedures and doctor visits after any applicable deductibles, coinsurances, and copayments

Medicare Supplementsecondary insurance to Medicare and has several different options. Larger provider options of doctors and hospitals compared to an Advantage plan. Usually prescription coverage is not included with a supplement.

Out of pocket maximum – this is the maximum an insured can pay on a policy. Usually this amount is the sum of the deductibles, co payments and coinsurance. Once the out of maximum has been met, the plan will pay 100% of the covered expenses until the next calendar year.

Reasonable and Customary Charge: Charge for health care service consistent with the going rate of charge in a given geographical are for a identical or similar services.

Waiting Period: Also known as elimination period. Duration of time between the beginning of an insured’s disability and commencement of the period for which benefits are payable.

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