Your health plan formulary may list a specific brand-name drug if a price agreement has been made with that company. This brand-name drug will cost more than the generic version, but cost less than other brand-name drugs that are not on the formulary. If you buy brand-name drugs that are not on the formulary, you often pay more because your health plan pays more. Insurance linked to military service.
ChampVA shares the cost of certain medically necessary procedures and supplies with eligible beneficiaries. ChampVA does not have a network of health care providers, so eligible members can visit most authorized providers. The federal agency that runs the Medicare program.
In addition, CMS works with the states to run the Medicaid programs. Participation in clinical research is voluntary. The informed consent form discusses who will pay the costs of services that are part of the clinical trial. Each study is different, but in many cases insurance will pay for medically necessary services that are part of the research study.
Sometimes research services are paid for by the study. Check with your insurance plan or the study team to determine coverage. The standard paper form used by healthcare professionals and suppliers to bill insurance companies. A federal law that protects employees and their families in certain situations by allowing them to keep their existing health insurance for a specified amount of time. COBRA provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates.
COBRA applies only under certain conditions, such as job loss, death, divorce or similar events. COBRA usually applies to group health plans offered by companies with more than 20 employees. Translating clinical information from your medical record into numbers such as diagnosis and procedure codes that insurance companies use to pay claims.
In many health plans, patients must pay for a portion of the allowed amount. Commercial health insurance is typically an employer-sponsored or privately purchased insurance plan. Commercial plans are not maintained or provided by any government-run program.
Commercial policies can be sold individually or as part of a group plan. An agreement you sign that gives you permission to receive medical services or treatment from doctors or hospitals.
A predetermined, fixed fee that you pay at the time of service. Copayment amounts vary by service and may vary depending on which provider in-network, out-of-network, or provider type you see. The amounts also may vary based on the type of service you are receiving for instance, primary care vs. For prescriptions, copayment amounts may vary depending on name-brand versus generic drugs. How insurance companies work together when you have more than one insurance plan. If you have more than one insurance plan, check with the secondary policy to find out how it covers expenses left over after your primary coverage has paid its part.
A 5-digit numbering system that helps standardize professional and outpatient facility billing. There is a CPT code for certain types of medical services. Using this code allows healthcare providers and insurance companies to communicate and track billing more efficiently.
The amount a patient pays before the insurance plan pays anything. In most cases, deductibles apply per person per calendar year. Some insurance plans waive the deductible for office visits. Some plans have service-specific deductibles.
A payment system used by many insurance companies for inpatient hospital bills. This system categorizes illnesses and medical procedures into groups. Hospitals are paid a fixed amount for each admission. The dollar amount removed from your bill, usually because of a contract between your provider and your insurance company. Drugs that do not require administration from doctors or nurses. Your insurance plan may not cover these when provided as part of an outpatient service.
The medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home. Services considered to be investigational are typically not covered by health insurance. If offered as part of a clinical research study, the study itself may cover the costs. Check with your insurance plan or study team if applicable to see if coverage is available for experimental or investigational treatments.
A statement sent to you by your insurance after they process a claim sent to them by a provider. The EOB lists the amount billed, the allowed amount, the amount paid to the provider and any co-payment, deductibles or coinsurance due from you. The EOB may detail the medical benefits activity of an individual or family. An employee benefit that allows a fixed amount of pre-tax wages to be set aside for qualified expenses.
Qualified expenses generally include out-of-pocket medical expenses. The amount set aside must be decided in advance and employees lose any unused dollars in the account at the end of the year. A list of preferred prescription medicines. The formulary sorts drugs into groups, or tiers, based on how much of the costs your health plan will pay and how much you have to pay.
Drugs with proven benefits that cost less because they are not made by major drug companies and do not carry brand names. In almost all cases, you pay the least out of pocket for drugs in this group. Not all drugs have generic options. The person responsible to pay the bill.
A five-digit numbering system that helps standardize professional and outpatient facility billing. There is a HCPC code for certain types of medical services. Health maintenance organization HMO refers to health insurance — These health insurance plans require enrolled patients to receive all their care from a specific group of providers except for some emergency care.
The plan may require your primary care doctor to make a referral before you can receive specialty care. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. A health plan refers to the type of health insurance you have.
An account associated with a high deductible health plan that allows you to set aside pretax dollars to pay your deductible or other qualified medical expenses. Unlike a flexible spending account, funds roll over and accumulate year after year if not spent. The federal Health Insurance Portability and Accountability Act sets standards for protecting the privacy of your health information.
A high deductible health plan HDHP with a health savings account HSA provides medical coverage and a tax-free way to save for future medical expenses. A high deductible health plan does not usually cover healthcare costs until the deductible has been met, which means you will be responsible for healthcare costs out-of-pocket until you meet your deductible. Once the deductible has been met, eligible healthcare expenses will be covered by the plan.
A group of doctors, hospitals and other healthcare providers preferred and contracted with your insurance company. You will receive maximum benefits if you receive care from in-network providers. The medical or surgical care unit in a hospital that provides care for patients who need more care than a general medical or surgical unit can provide.
ICDCM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. Plans can put an annual dollar limit and a lifetime dollar limit on spending for healthcare services that are not considered essential health benefits.
The essential health benefits include at least the following:. Insurers must notify consumers with these policies that have a grandfathered plan. Medicaid is a jointly funded federal and state health insurance plan administered by states for low income adults, pregnant women, children and people with certain disabilities.
For additional information, please see Your Health Insurance Coverage. Medicare is a federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD. For additional information, including explanations of the different parts of Medicare, please see Your Health Insurance Coverage.
A Medicare HMO insurance plan that pays for preventive and other types of healthcare provided by designated doctors and hospitals. A type of Medicare health plan offered by an insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits, plus benefits that Original Medicare does not cover. Providers who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.
A Medicare card with a unique number is assigned to each person covered under Medicare. The number is used by providers for billing, eligibility and claim status. Usually referred to as Hospital Insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs. Assists with paying for doctor services, outpatient care and other medical services not paid for by Medicare Part A. A statement that Medicare sends to you after they process a claim from a provider for services provided to you.
The EOMB lists the amount billed, the allowed amount, the amount paid to the provider and any copayment, deductible or co-insurance due from you. The EOMB may detail the medical benefits activity of an individual or family. Policies that supplement Medicare coverage. Most times, these policies pay the Medicare co-pays and deductibles, but nothing extra. Check with your supplemental insurance to find out how it coordinates benefits with Medicare.
A group of doctors, hospitals, pharmacies and other healthcare experts hired by a health plan to take care of its members. The charges for medical services denied or excluded by your insurance.
You may be billed for these charges. A doctor, hospital or other healthcare provider that is not part of an insurance plan, doctor or hospital network. A doctor or other healthcare provider who is not part of an insurance plan, doctor or hospital network. See " Non-participating provider ". A doctor, hospital or other healthcare provider who is not part of an insurance plan, doctor or hospital network.
The costs the patient is responsible for because Medicare or other insurance does not cover them. The most money you will have to pay before your insurance company covers all costs.
Each plan sets a dollar limit for the calendar year. Coinsurance : The co-payment a member makes based on a percentage of the costs of the medical services received, usually around 10 to 20 percent.
Coinsurance is usually found in indemnity, fee-for-service and PPO plans, often along with deductibles. Confidentiality : The ability to speak with the provider or representative without disclosing the information to an uninterested party. Coordination of Benefits : A process that applies when determining which plan or insurance policy will pay first if multiple policies exist. Unlike coinsurance, this amount is not based on a percentage of the actual cost of services, but is pre-determined.
Covered Charges : Services or benefits for which a health plan makes either partial or full payment. Deductible : The annual amount payable by the beneficiary for covered services before Medicare makes reimbursement. Deductible Medicare : The dollar amount that a member must pay for medical services before health plan coverage begins. It is the "parent" of CMS.
Determination : A decision made to either pay in full, pay in part, or deny a claim. Diagnosis : The name for the health problem the patient presented with or was treated for during an encounter or communication with the provider.
Disclosure : Release or divulgence of information by an entity to persons or organizations outside of that entity. Durable Medical Equipment DME : Medical equipment that is ordered by a provider for patient use outside of the facility which can withstand repeated use, is not disposable, is used to serve a medical purpose and is appropriate for the home. Eligibility : Refers to the process whereby an individual is determined to be eligible for health care coverage through their plan.
The statements informs what the provider billed for, the plan's approved amount and how much they paid. Fee Schedule : A comprehensive list of all services provided and their respective charge. Fee-for-Services : A method of paying the provider for service or treatment based on the fee schedule. Formulary : A list of certain drugs and their proper dosages.
In some health plans, doctors must order or use only drugs listed on the health plan's formulary. Gatekeeper : In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.
Grievance : A complaint about the way health care service, process or payment were handled. Guarantor : The person responsible for payment of rendered services. The guarantor is customarily the person bringing the patient in for treatment.
This person is not necessarily the same as the subscriber. Health Care Provider : A person who is trained and licensed to give health care. Also, a place licensed to give health care.
Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities, and certain kinds of home health agencies are examples of health care providers. An Administrative Simplification section in the law requires adoption of standards for security, privacy and electronic healthcare transactions.
Health Maintenance Organization HMO : A legal corporation that provides health care in return for pre-set monthly payments. For most HMOs, members must use the physicians, hospitals and other health care professionals in the HMO's network in order to be covered for their care.
Health Plan : An entity that assumes the risk of paying for medical treatments, i. Indemnity : This is a form of coverage offered by most traditional insurers. An indemnity plan reimburses the patient directly medical costs regardless of who provided them.
Interest : A payment for the use of money during a specified period. May also be a form of penalty for non-timely reimbursement. Letter of Request : A formal request from the requestor detailing informational needs and purposes. Managed Care : A term originally coined to refer to the prepaid health care sector e. Managed Care Organization MCO : A health plan that provides coordinated health care through a network of primary care physicians and hospitals for pre-set monthly payments.
Medicaid : A health plan that provides coordinated health care through a network of primary care physicians and hospitals for pre-set monthly payments. A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. Medically Necessary : Services or supplies that are proper and needed for the diagnosis or treatment of your medical condition; are provided for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local area; and are not mainly for the convenience of the patient or provider.
The period for a deductible runs from January to December of every year and is called Calendar Year. Defined Benefit Plan Employer sponsored health plan to provide workers with health benefits. An employer chooses a specific package of benefits to offer workers. The employer then asks health plans for a price for this intended benefits package.
A defined benefit plan is different from a defined contribution plan. Defined Contribution Plan Employer sponsored health plan to provide workers with health benefits. In the defined contribution plan, each employee is given a set amount of money with which he or she can make the health plan purchasing decision by himself or herself.
The employer is removed from being the intermediary. A defined contribution plan is different from a defined benefit plan. Denial Non-payment or non-authoriztion of a request for care, services, or claim payment. Denials are made if something is not medically appropriate or if it is not included as a benefit in the insurance coverage.
Dental Benefits Some health plans offer dental care coverage as an optional benefit or rider that may be added at an additional cost. Dependents A spouse, parent, other family member or other individual who fits the eligibility requirements for insurance coverage under the named insured. Disenrollment The procedure of dismissing individuals or groups from their enrollment with a health carrier.
Dual Choice The employer is allowed to offer employees not one, but two health plans, which best meet their needs or budgets. Duplication of Benefits Overlapping or identical health coverage of an insured person under two or more plans. Durable Medical Equipment Equipment appropriate for home use that serves a medical purpose for a person who is ill or injured.
Examples include hospital beds, wheelchairs, and oxygen equipment. Durable Power of Attorney Advance instructions from a patient to pre-designate another individual to make health care decisions in the event of that the patient becomes incapacitated through illness or trauma.
This designated person then holds a power of attorney for the patient, but only for health care decisions. Effective Date The date health insurance protection begins. Elective Service An inpatient or outpatient procedure that benefits a patient but is not essential to survival.
Eligible Dependent A dependent of a covered employee who meets the requirements specified in the group contract to qualify for health coverage. Eligible Employee An employee who meets the eligibility requiremenst specified in the group contract to qualify for health coverage. Eligibility The employer determines if a subscriber is eligible to receive services that are covered by the insurance plan.
Elimination Period Specified number of days that a person must be eligible for coverage or disabled before a policy begins to pay benefits.
Emergency Care Suggested with the sudden onset of severe or painful symptoms that would place a patient in serious jeopardy. In the event of a life-threatening emergency, patients should go to the nearest emergency room for treatment. Prior authorization is not required, but patients should notify their primary care provider within 24 hours, or as soon as is reasonably possible, so that appropriate, coordinated care can be arranged.
The same procedure applies to out-of-area emergency care. Emergency care is not the same as urgent care. See Urgent Care Emergicenter A health care facility, for which the primary purpose is the provision of immediate, short-term medical care for urgent medical conditions. Also called a Freestanding Outpatient Surgical Center. Employee Contribution The portion of the insurance premium paid by the employee. ERISA allows some large employers to operate benefit plans exempt from state government regulations.
ERISA also mandates the reporting and disclosure requirements for group life and health plans. Employer Sponsored Insurance Group health insurance coverage that is purchased and offered by an employer.
The coverage can be through a private insurance company, or it can be what is called "self-funded" or "self-insured. Enrollee Any person an employee or dependent who is properly enrolled with an insurance plan. Enrollee and member are used interchangeably.
Evidence of Insurability Form that documents an individual s eligibility for health plan coverage when the person does not enroll in the open enrollment period. When an employee wants to switch to a different health plan in the middle of a contract year, the new health plan may require written information and a physical examination as proof that it will not be accepting a high risk patient. Exclusions and Limitations Conditions or circumstances that limit or exclude benefits payments.
Exclusions can be suicide, self-inflicted injuries, war injuries, on-the-job accidents covered by workers' compensation, eye or dental treatment, cosmetic surgery, those services for which no charge is made, and services that are not medically necessary. Some policies also may limit or exclude treatment for mental illness or substance abuse.
Experimental Procedures Otherwise known as investigational or unproved procedures, this covers all health care services, supplies, treatments, or drug therapies that have been determined by the health plan to not be generally accepted by health care professionals as an effective means of treating the illness for which their use is proposed. Experimental procedures are said to not be proven scientifically effective in treating the condition for which their use is prescribed.
Explanation of Benefits A form sent by the insurance company after a claim has been made detailing whether or not the claim has been paid and why. Extended Care Facility A nursing home or similar setting which offers skilled, intermediate, or custodial care. The insurance company pays all, or a portion of, the bills after services are received by the insured.
Deductibles may have to be paid before the policy begins to pay, and co-payments may have to be paid each time there is a claim.
Also called Cafeteria plans Formulary A list of the drugs and medications that an insurance company will pay for when a doctor prescribes them. Formularies are used by most managed care plans and vary by insurance company and insurance plan design. A physician is required to use only formulary drugs unless there are valid medical reasons to use a nonformulary drug.
Freestanding Emergency Medical Service Center A health care facility that is physically separate from the hospital that provides prescheduled, outpatient surgical services. Also called a surgicenter. Gatekeeper A primary care physician who is responsible for managing all clinical aspects of the care for a patient who is enrolled in an HMO. These responsibilities include administering the patient s treatment and coordinating and authorizing all medical services, laboratory studies, and hospitalizations.
Also see PCP. Generic Drugs An equivalent to a brand-name drug that is usually less expensive. Most insurance companies that provide drug benefits cover generic drugs but may require a member to pay the difference between a generic and a brand-name dug or pay a higher copay, unless there is no generic equivalent.
Geritrician A medical specialist in the field of geriatrics, the branch of medicine dealing with the physiology of aging, and the diagnosis and treatment of diseases affecting the aged. Gerontologist A specialist in the scientific study of the sociological, clinical, biological, historical issues involved with aging.
Different from a geriatrician, who is interested generally in the biological and clinical issues of aging. Grievance A formal complaint. Group Health Insurance Plans Health insurance offered through an employer or association.
Health Care Provider Healthcare professionals who provide medical treatment and services. Health Maintenance Organization - HMO Organized system for health care that provides comprehensive services directly to enrolled members for a fixed fee.
HMOs provide or arrange for health care services through a network or group of health care providers that are coordinated by the enrollees' primary care physician for routine office visits, diagnostic tests, hospital care, surgical care, emergency care and preventive services. Some laws will pertain to the standardization of health insurance forms using common terms. Other regulations will outline ways to protect the privacy of an individual's personal health information.
HMO Act of Federal law that required employers with more than 24 employees to offer an alternative to conventional indemnity health insurance in the form of a federally qualified HMO. The main intention of the Act was to encourage HMO development. Home Care Medical care for a patient who is not able to make frequent office or hospital visits. For example, a health care professional can administer intravenous therapy at the patient s residence. Home care reduces the need for patient hospitalization and the associated costs.
ICDCM International Classification of Diseases A listing of diagnoses and identifying codes used by doctors and other healthcare providers to describe a patient s diagnosis. It is a uniform language that all healthcare providers use to be paid for the treatments and services they provide to patients. Indemnity Health Insurance Also known as traditional or fee for service health insurance. The insurance company pays all or, a portion of, the bills after services are received by the insured.
Enrollees are not required to stay within a managed care system. Individual Health Plans Health insurance purchased directly by an individual through an insurance company.
People not covered by a group plan, or who want different or additional coverage other than that offered by the employer, can buy individual health insurance coverage or determine their eligibility under government sponsored health insurance.
Inpatient Services Services that are ordered by a doctor for a patient who is in the hospital. Length of Stay The number of consecutive days a patient is hospitalized. Lifetime Maximum The maximum amount of money a plan will pay toward a healthcare service over the course of the insured's lifetime. Limited Fee Schedule A fee structure under which the insurance company places limits caps on the dollar amounts it will reimburse providers for medical procedures and services.
Living Will A form of advance directive, whereby the patient signs a document instructing what care can be withheld or utilized in case of incapacitating illness or trauma. Long-Term Care Services ordinarily provided in a skilled nursing, intermediate care, personal care, supervisory care, or elder care facility.
Mail Order Pharmacy A method of dispensing medication directly to the patient through the mail. Mail-order drug distributors can purchase drugs in larger volumes than retail or wholesale outlets. Major Medical Insurance Plan A traditional type of medical expense coverage providing substantial benefits for hospital surgical expenses and physician's fees.
Managed Care A term that includes health maintenance organizations HMOs , preferred provider organizations PPO s , integrated delivery systems, and others. These programs vary in provider choice, convenience and costs. Mandated Benefits Health benefits that health care plans are required by state or federal law to provide to members.
A high-deductible insurance policy must also be purchased with a Medical Savings Account to pay for the high costs of severe illness or injury. Funds that are not used in the account by the end of the year are rolled over to the next year. Medical Service Organization MSO An integrated health care delivery network that contracts with payers to provide a comprehensive array of benefits.
Medicare Medical coverage for individuals aged 65 or older, for those who have permanent kidney failure, and for certain people under 65 years of age who have disabilities.
Medicare is the nation s largest health insurance program, covering approximately 39 million Americans. Medicare Supplement Policy also Medigap Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. Since Medicare pays physicians for services according to their own fee schedule, regardless of what the physician charges the individual may be required to pay the difference between Medicare s reimbursable charge and the physician s fee.
Medigap insurance is meant to fill this gap in reimbursement, so that the Medicare beneficiary is not at risk for the difference.
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