Florida
Health Insurance GlossaryCoinsurance
. . . Copayment . . . EOB . . . What does it all mean? At
eFLHealthInsurance
,
we understand how confusing it can be to decipher all the insurance terms and
acronyms that come with purchasing a health plan. Therefore, we’re
providing you with the definitions of the most commonly used insurance terms and
acronyms. When
reading the definitions, please keep in mind that this glossary is provided as
a general guide. These definitions are for illustrative purposes only and
are not meant to be exhaustive. Definitions and plan options may vary by
state and plan. If you obtain coverage, please refer to your contract for
a complete listing and exact definition of terms, as your contract language will
prevail.
A Ancillary
Services - services, other than those provided by a physician or hospital,
which are related to a patient’s care, such as laboratory work, x-rays and
anesthesia. C Calendar
Year - the period beginning January 1 of any year through December
31 of the same year. Case
Management - a process
whereby a covered person with specific health care needs is identified and a plan
which efficiently utilizes health care resources is designed and implemented to
achieve the optimum patient outcome in the most cost-effective manner. Certificate
of Coverage - a document given to an insured that describes the benefits,
limitations and exclusions of coverage provided by an insurance company. Claim
- Information a medical provider or insured submits to an insurance company to
request payment for medical services provided to the insured. Coinsurance
- The portion of covered health care costs for which the covered person has a
financial responsibility, usually a fixed percentage. Coinsurance usually applies
after the insured meets his/her deductible. Consolidated
Omnibus Budget Reconciliation Act (COBRA) - a federal law that, among
other things, requires employers to offer continued health insurance coverage
to certain employees and their beneficiaries whose group health insurance has
been terminated if they undergo a triggering event. Contract
Year - the period of time from the effective date of the contract to
the expiration date of the contract. Coordination
of Benefits (COB) - a provision in the contract that applies when a
person is covered under more than one medical plan. It requires that payment of
benefits be coordinated by all plans to eliminate overinsurance or duplication
of benefits. Copayment
- a cost-sharing arrangement in which an insured pays a specified charge for a
specified service, such as $25 for an office visit. The insured is usually responsible
for payment at the time the service is rendered. This charge may be in addition
to certain coinsurance and deductible payments. Covered
Person - an individual who meets eligibility requirements and for whom
premium payments are paid for specified benefits of the contractual agreement. Covered
expenses - services for which the health insurance makes either a full
or partial payment. 
D Deductible
- the amount of eligible expenses a covered person must pay each year from his/her
own pocket before the plan will make payment for eligible benefits. Deductible
Carry Over Credit - charges applied to the deductible for services
during the last 3 months of a calendar year which may be used to satisfy the following
year’s deductible. Dependent
- a covered person who relies on another person for support or obtains health
coverage through a spouse, parent or grandparent who is the covered person under
a plan.
E Effective
Date - the date
insurance coverage begins. Eligible
Dependent - a dependent
of a covered person (spouse, child, or other dependent) who meets all requirements
specified in the contract to qualify for coverage and for who premium payment
is made. Eligible
Expenses - the lower of the reasonable and customary charges or the
agreed upon health services fee for health services and supplies covered under
a health plan. Emergency:
the sudden, and at the time, unexpected onset of a health condition that requires
immediate medical attention where failure to provide medical attention would result
in serious impairment to bodily functions or serious dysfunction of a bodily organ
or part, or would place the person’s health in serious jeopardy. Explanation
of Benefits (EOB)
- the statement sent to an insured by their health insurance company listing services
provided, amount billed, eligible expenses and payment made by the health insurance
company.
F Formulary
- a list of particular
prescription drugs for which an insurer provides additional coverage or a lower
copay. H Health
Savings Account - special plans in which money can be deposited into
a tax-deferred health savings account from which you can withdraw money on a pre-tax
basis for qualified medical care and expenses. I Insured
- a person who has obtained health insurance coverage under a health
insurance plan. L Lifetime
limit - the total maximum the policy will pay. Most plans have
at least $1 million, and many have $2- to $5 million in lifetime coverage.
M Managed
Care - a health
care system under which physicians, hospitals, and other health care professionals
are organized into a group or “network” in order to manage the cost,
quality and access to health care. Managed care organizations include Preferred
Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). N Network
- doctors, hospitals, and other medical providers that are contracted
to provide services for a particular plan. PPO members have less out-of-pocket
expense when they use network providers.
O Out-of-Pocket
Maximum - the total payments that must be paid by a covered person
(i.e., deductibles and coinsurance) as defined by the contract. Once this limit
is reached, covered health services are paid at 100% for health services received
during the rest of that calendar year. Outpatient
medical care: non-surgical services provided
in a provider’s office, the outpatient department of a hospital or other
facility, or the member’s home.
P Participating
Provider - a medical provider who has been contracted to render medical
services or supplies to insureds at a pre-negotiated fee. Providers include hospitals,
physicians, and other medical facilities. Physician:
A doctor of medicine or osteopathy who is licensed to practice medicine under
the laws of the state or jurisdiction where the services are provided. Pre-existing
condition - a health problem that existed before your coverage
went into effect. Many plans won't cover preexisting conditions. Preferred
Provider Organization (PPO)
- a health care delivery arrangement which offers insureds access to participating
providers at reduced costs. PPOs provide insureds incentives, such as lower deductibles
and copayments, to use providers in the network. Network providers agree to negotiated
fees in exchange for their preferred provider status. Premium
- the amount you pay (usually monthly) for your insurance. Preventive
care:
comprehensive care that emphasizes prevention, early detection and early treatment
of conditions through routine physical exams, immunizations and health education. Provider
- a physician, hospital, health professional and other entity or institutional
health care provider that provides a health care service. Primary
Care Physician (PCP) - a physician that is responsible for providing,
prescribing, authorizing and coordinating all medical care and treatment. Note:
PPOs typically allow you to go to any doctor in the network, and do not require
that you consult with a PCP. Prescription
drugs:
prescription drugs include:
- Brand name prescription
drug: the initial version of a medication developed by a pharmaceutical manufacturer
or a version marketed under a pharmaceutical manufacturer's own registered trade
name or trademark.
- Legend
drug: a medicinal substance, dispensed for outpatient use, which under the
Federal Food, Drug & Cosmetic Act is required to bear on its original packing
label, “Caution: Federal law prohibits dispensing without a prescription.”
- Formulary:
a list of pharmaceutical products developed in consultation with physicians and
pharmacists and approved for their quality and cost effectiveness.
- Generic
prescription drug: drugs determined by the FDA to be bio-equivalent to brand
name drugs and that are not manufactured or marketed under a registered trade
name or trademark.
R Reasonable
and Customary (R &C)
- a term used to refer to the commonly charged or prevailing fees for health services
within a geographic area. A fee is generally considered to be reasonable if it
falls within the parameters of the average or commonly charged fee for the particular
service within that specific community. Note: charges within a PPO network are
not normally limited to reasonable and customary fees.
U Underwriting
- the act of reviewing and evaluating prospective insureds for risk assessment
and appropriate premium. Usual
and customary charge - the amount a plan will pay for a particular
procedure, usually based on a prevailing average. W Well-child
visit: a physician
visit that includes the following components: an age-appropriate physical exam,
history, anticipatory guidance and education (e.g., examining family functioning
and dynamics, injury prevention counseling, discussing dietary issues, reviewing
age-appropriate behaviors, etc.), and assessment of growth and development. For
older children, a well-child visit also includes safety and health education counseling.
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