Consolidated Omnibus Budget Reconciliation Act
of 1986. Terminated employees or those who lose coverage because of
reduced work hours may be able to buy group coverage for themselves and
their families for limited periods of time.
The amount you must pay for medical care in a
point-of service plan (POS) or preferred provider organization (PPO)
after you have reached your deductible. It is often a percentage of
A charge you pay for medical services. Your
health care plan covers the remaining medical charges. As an example,
you may pay $10.00 for an office visit or a prescription.
The amount of money you must pay each year for
coverage to your medical care expenses, before your insurance policy
begins to pay.
Specific conditions or circumstances in which
the policy will not offe benefits.
Fee- for- Service-
Payment agreements for health care in which
the provider is paid for each service, rather than a pre-negotiated
amount for the patient.
Health Insurance Portability and
Accountability Act of 1996. It is designed to protect health insurance
coverage for workers and their families when they change or lose their
HMO- (Health Maintenance Organization) -
Prepaid health plans for which a premium is
due each month. The HMO covers your cost of care to see a doctor within
their working network at pre-negotiated rates. You are required to
choose a primary care physician who takes care of you and makes
referrals to any specialists you may need. If you, as an HMO member, do
not use the doctors, hospitals and clinics that do not participate in
your plan’s network, you may be required to pay the cost of those
IPA (Independent Practice Association) -
An independent group of physicians who unite
with an HMO to offer services for the HMO members.
Lifetime Maximum -
The maximum percentage of benefits available
to a member during their lifetime, in which, all benefits served are
subject to this limit unless stated as unlimited.
MSA (Medical Savings Account) -
A tax-advantaged personal savings account used
along with a high deductible health policy. You may deposit money into
this account on a pre-tax basis to set aside money for medical care and
expenses that qualify, including annual deductibles and co-payments.
The highest amount of money you will pay in a
year for deductibles and coinsurance plus regular premiums.
Point-Of-Service (POS) Plan -
A certain managed care plan combing features
of health maintenance organizations (HMOs) and preferred provider
organizations (PPOs). You may choose whether to go to a network
provider and pay a flat dollar amount or to an out-of-network provider
and pay a deductible and/or coinsurance charge
Pre-existing Condition -
A health problem that existed or was treated
before your insurance became in effect. Most health insurances have a
pre-existing condition plan that describes under what conditions they
will cover medical expenses that relate to a pre-existing condition.
PPO (Preferred Provider Organization) -
A network of health care providers that offers
medical services to health plan members at a discounted cost. PPO
members usually make their own decisions about their health care
instead of going through a primary care physician like an HMO member.
The costs to use physicians within the PPO network are less than using
a non-network provider.
The amount you must pay in exchange for health
Primary Care Physician -
Under a health maintenance organization (HMO)
or point-of-service (POS) plan, a primary care physician is often the
first contact for health care. It is usually a family physician,
internist, or pediatrician. A primary care physician makes referrals to
specialists if necessary.
Any person (doctor or nurse) or institution
(hospital, clinic, or laboratory) which is certified, that provides
Well Baby -
Health services, which include immunizations
provided by the member’s participating medical group, up to a certain
age as specified by the carrier. This benefit is usually provided in
HMO plans and/or POS plans. The level of benefit will vary for PPO
plans if specified as a benefit.