Annual or lifetime maximum. An upper limit on costs or services covered by a plan. For example, a plan may limit a member to 60 days of occupational therapy or put a ceiling on the dollar amount of coverage it will provide over a member's lifetime. Some plans have limits; some don't.
Members have to file a claim form to get reimbursement from their insurance company after a provider office visit, lab test, or hospital visit. The claim form usually ask for information regarding a member such as name, address, insurance policy number, reason for office visit, etc. The member can attach a copy of receipt from a medical provider with the claim form.
Most medical providers file claims on behalf of their patients. However, many doctors ask their patients for payment during office visits and ask patients to file claims themselves so that office staff do not have to spend time dealing with insurance companies to get claims paid. Members will have to address billing errors on their own if their claims are not processed correctly.
Most claim disputes arise when a claim is denied by an insurance company. In some cases, members and their insurance companies are able to resolve their disputes amicably and get claims paid. This often means that, at a minimum, members need to contact their insurance companies to clarify any paperwork requirements or resolve misunderstandings about insurance coverage, ask their doctors to provide new information or submit additional documentations.
The process can be tricky as some insurance companies only pay a disputed claim unless provider provide the exact medical diagnosis code for the office visit. This means that it is possible for a member to get a procedure covered with one doctor or experience a claim denial for the same medical providers if one of these providers fail to supply the exact medical procedure code for the patient's claim form.
Members can file appeals for their claims to resolve claim disputes with their insurance company. Different insurance companies have different appeal policies - most typically assign a medical director or lower level staff to review initial appeal. Members may also ask their doctors to help explain why care is needed. In some cases, a government agency may join in appeal process and demand insurance company to make more member-friendly decisions or enforce specific insurance rules and regulations.
Co-payment or co-insurance
A dollar amount or percentage a member is responsible for paying for covered health care services. A member may have to pay a set amount every time he/she makes an office visit, a different amount for lab work, and various amounts for different types of prescription drugs. A member usually have to meet a deductible before his/her co-pay or coinsurance kicks in.
The amount that a member has to pay for covered medical services (generally each year, although some plans have a separate hospital deductible for each hospital admission) before a member's health plan starts chipping in. The deductible amount may be very small or quite large, depending partly on the member. A member usually can get a plan with a high deductible for a lower premium. This is a good way to save money for people who are young, healthy, and have no children.
A health condition or service not eligible for coverage under a member's health plan. What a plan doesn't covered is listed in a member's coverage document called a Certificate of Coverage or Summary Plan Description.
explanation of benefits
A member gets an explanation of benefits (EOB) every time he/she or his/her doctor files a claim with the insurance company. The EOB explains how a member's health claim was processed. The form usually includes: date of service, who provides the service, the service provided (in code number or abbreviations), the claim amount, the agreed-upon-amount paid by the insurance plan, and amount a member is responsible for paying.
Under a fee-for-service plan, members will get reimbursed for a percentage of the cost of any provider visit. Members can pick any providers regardless of whether these providers are affiliated with a provider network with a specific insurance company. However, members can incur unexpected out-of-pocket expense if their medical providers charge rates that are above what's considered "reasonable" according to their insurance companies.
Some insurance companies set higher "reasonable" rates while other companies are less generous. Under this scenario, members will be liable for higher out-of-pocket expense since their insurance company will only cover a set percentage of "reasonable" rate, not the actual provider charge, for a specific office visit or medical procedure.
First-dollar plans don't have a deductible and payment for covered benefits from the first dollar a member spends on health care. The term first-dollar plan may also describe a plan with a deductible that also has a benefits account that a member can use to pay for medical services before he/she meets the deductible requirement. Many plans with deductibles provide first-dollar coverage for preventative services.
flexible spending account (fsa)
Some employers provide FSA to help employees use pre-tax money to pay for eligible health care expenses and day-care costs for children. However, any FSA money left at year-end will be kept by the employer. This means that employees have to be careful in estimating their potential health care and dependent care expenses when deciding how much to contribute to FSA when they select their health insurance plans during annual plan enrollment.
health savings account (HSA)
Members can contribute tax-free money into a HSA if they select a high deductible health insurance plan. There is an annual maximum of $ 5,800 per year per family. HSA works much like a medical IRA (Individual Retirement Account) that retirees can withdraw HSA money to pay for health related expenditures.
health reimbursement arrangement (HRA)
Some employers provides money to help members pay deductibles and covered expenses via HRA. Employers typically define how employees can use the money. Any left over HRA at year-end will remain in the account provided members stay in the same health insurance plan the following year.
health maintenance organization (hmo)
In a HMO, members have to select a Primary Care Physician (PCP), to coordinate care and make referrals to specialist when needed. Most members pick a family doctor, an Obstetrician/Gynecologist, or Pediatrician (for children) as their PCP. Members are encourage to use providers within their HMO network and minimize the use of specialist (with PCPs serving as gate-keepers to limit specialist referrals). They have to pay more of the cost or the full cost if they seek care from out-of-network providers without authorization from their insurance company.
The cost of a health plan. An employer usually pay part of a member's health insurance premium if the employee get health benefits through the company. Most large employers contribute 70%-80% of the total premiums paid to the insurance company.
HMO members get care from providers, i.e., doctors, labs, hospitals, affiliated with the designated network assigned by their insurance companies. Most health plans encourage in-network care because insurance companies have negotiated discounts with in-network providers and establish programs to motivate providers to deliver cost-effective care.
HMO members get care from providers, i.e., doctors, labs, hospitals, outside of designated network assigned by their insurance companies. In most cases, members use of-of-network care to get better quality care or access from specific hospitals or medical providers. Most health plans try to limit out-of-network care because insurance companies have little control over provider cost and utilization of care.
The money that members have to pay on their own after they get reimbursement from their insurance companies for medical care. This include the sum total of co-payment for office visits plus non-covered charges. Members with a high deductible plans tend to have high out-of-pocket expense because they are liable for the full medical charge for a particular medical visit until their cumulative out-of-pocket spending reaches the limit set by their annual deductible amount.
Under a PPO, members do not have to designate one doctor as a Primary Care Physician (PCP). They can choose any doctor within the network as specified by their insurance companies. The net benefit is the freedom to choose any doctor within a network and the elinination of the need to ask referrals for seeing medical specialists or medical needs so long as the providers are affiliated with the PPO network.
point of service (POS)
POS is a combination of an HMO and a PPO. Members can choose to get care from both networks and access specialists in the PPO network without the hassle of getting their PCPs to grant specialist referrals.
The need to ask permission from a PCP and health insurance company to to see medical specialists or obtain treatment for specific medical conditions.
primary care physician (PCP)
In a HMO, members have to select a Primary Care Physician (PCP), to coordinate care and make referrals to specialist when needed. Many members pick a family doctor as their PCP. Many women pick their Obstetrician/Gynecologist when parents select Pediatrician as their children's PCP. Most insurance companies have incentive programs for PCPs to encourage cost effective care and minimize member access to specialist care. In other words, PCPs are also insurance companies' gate-keepers.
A payment either to a member or a health care professional for covered medical services. A fee-for- service plan may reimburse a member or doctor a set amount or maximum amount for specific services. This system can lead to larger out-of-pocket costs for a member when he/she have to pay the difference between what his/her doctor charges and what a member's plan pays. However, a health plan may negotiate fees in advance so the doctor cannot bill a patient for the balance.
Insurance companies set rates that they consider "reasonable" for different geographic areas. Some insurance companies set higher "reasonable" rates while other companies are less generous. Members will incur higher out-of-pocket expenses if their providers charge rates that are higher than what's considered "reasonable" according to their insurance companies. Insurance companies will only pay a set percentage of "reasonable" charge, not the actual provider charge.
Medical providers that specialize in a specific areas, i.e., cardiologist, ear & nose specialist, dermatologist, infertility specialist, etc. These doctors tend to charge high rates for office visits and perform more expensive diagnostic tests. Thus, health insurance companies in general try to discourage use of specialist care. Members typically have to ask their PCPs for a specialist referral when they need the service.
HMO members have to ask their Primary Care Physician (PCP) for a specialist referral when they need to see a medical specialist. They are liable for total specialist care charges if they do not obtain authorization from their PCP and their insurance companies prior to seeing their specialist doctors. Many health plan members often cite ease of getting specialist referral as a key reason for selecting a PPO over a HMO plan.