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GLOSSARY
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Terms: Aggregate Deductible: The combination of expenses collectively met by all family members to meet the deductible. Association-based coverage: carriers that require clients to join an association. Claim: The charge by the physician, pharmacy, hospital, or clinic for services rendered.
Cobra: The continuation of your health insurance policy with your employer post employment. This coverage will be terminated after 18 months.
COBRA STANDS FOR: Consolidated Omnibus Budget Reconciliation Act. Guarantee Issue health insurance once you have 18 months of continuous Cobra coverage. You must have a certificate or proof of 18 months of continuous coverage, and you have 63 days to get the HIPPA insurance. If you are one day late, you will not get the insurance.
Co-Insurance: Once the deductible is met, this is the portion that is shared by the client and the insurance company. It is the difference between the deductible and the maximum out of pocket. Usually an 80/20 or 70/30 split. The lower number or percentage is what the client is responsible for. For example if the medical bill is $2000, and the deductible is $1000, and the co-insurance is 80/20, your client would owe, $1200. The percentage of a bill the client owes after the deductible is met.
Contracted Rate: The Insurance Company negotiates the rate the hospital, clinic, or doctor can charge and still have it covered by the insurance. This fee is pre-determined, and is the amount of money the Insurance Company pays the physician, pharmacy, hospital or clinic.
Co-pay: The flat fee you pay for specific areas of the policy, where the deductible does not apply. For example: $30 Physician Visit, $50 Preventative Care, $50 Urgent Care, Medication $10 Generic, $35 Brand, and $55 Non Brand.
Decline: When an application has been denied by the health insurance company due to health issues. Deductible: The financial exposure at the bottom of the spectrum or policy that the prospect will be responsible for, before the benefit begins. This does not include co-pays. This applies to PPO policies. The amount of money a client owes before coinsurance takes effect.
Effective Date: The date your policy begins.
EME: Estimated Medical Expense, or Usual and customary fee or charge for a procedure or service.
EOB: Explanation of benefits. The client will receive an EOB anytime a claim is filed.
ER: Emergency Room.
Global Billing: An all inclusive pre-determined rate. All OB (Maternity) providers submit their claims at the time of delivery and are paid a global fee. Grace Period: Period of time given by insurance company to allow client to pay the monthly premium. If client does not pay premium within the grace period, which is usually 30 days, then the prospects coverage will be terminated on the last day of the month when premium was last paid.
Group Insurance: Insurance for a group of at least two persons that are a business. This is a BUSINESS or COMPANY policy. Prospective company will need quarterly wage and tax information on associates.
Guarantee Issue: Every applicant is approved for health insurance no matter the health condition. HIPPA and Group would apply.
HIPPA: A signed release by person that allows physician, pharmacy, hospital, clinic or any medical provider to share person's personal health history or records.
High Risk Pools: Program provided by certain states for the un-insurable. This can be a life saver for those people can’t qualify for any health insurance based on their medical history.
HMO: Health Maintenance Organization. HRA: Health Reimbursement Account.
HSA: Health Savings Account.
Individual Application/Policy: Health Insurance policy, program or application for individual, husband and spouse, male applicant and children, and female applicant and children.
In Network: Physicians, pharmacies, hospitals and clinics that the Insurance Company is contracted with.
Limited Benefit Plans: also called "scheduled" plans that place limitations on most plan features. Most of them are guaranteed issue regardless of medical history. Major Medical: a term to describe comprehensive plans. Maternity Waiting Period: A period that begins on the effective date of coverage. The waiting period can range from 3 – 12 months and varies by plan. Maximum or Lifetime Benefit: The total amount the insurance company will pay.
Maximum Out of Pocket: The total financial exposure a client has with their policy.
MIB: Medical Information Bureau. Network: Doctors, Hospitals, Labs, and other facilities that have a contract with a carrier. Non-underwritten: A plan that does not go through underwriting or a "guaranteed issue" plan.
OOP: Out of Pocket. This is the most a client is responsible for before the carrier pays 100%.
Out of Network: Physicians, pharmacies, hospitals and clinics that the insurance company is NOT contracted with.
PPO: Preferred Provider Organization. Pre-Existing Condition: Health conditions that you have, which has been documented and diagnosed by a doctor during the past 5 to 10 years. This applies to the last 5 years with most insurance companies. Premium: The monthly fee a prospect will pay for the health insurance.
Pre-screen: the process of contacting the carrier regarding pre-existing conditions.
Preventative: also known as "wellness" relating to physicals, OB/GYN visits, mammograms, etc.
Prior Authorization: Physician or physician’s office will need to call into the Insurance Company for authorization for medication or procedure before approval. Without the prior authorization on some proceeds the Insurance Company will refuse to cover the cost.
Rate Up: When the initial insurance premium for a prospect is increased by the insurance company based on pre-existing conditions that were found during the underwriting process.
Rider: An addition to coverage in a policy that in most cases also increases the premium and sets a time period where the condition won’t be covered by the insurance company. This time period can run from 1 to 5 years depending on the health condition.
Underwriting: The process of reviewing your Health Insurance application for accuracy, completeness, and verify your past medical history. Based on the discovery and verification of information the Insurance Company will make a decision to approve or decline your application.
UR: Urgent Care.
UW: Underwriting
Waiver: When a prospect has a pre-existing health issue that will NOT be covered by the insurance company for a defined period of time. Wellness: See preventative.
Write-Off: All monies billed by the physician, pharmacy, hospital or clinic which are more than the contracted rate allows. The difference is "written off", as the client or insurance company only pay the contracted rate.
