Coinsurance
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Specified percentage (typically 20% to 30%) of covered medical expenses that an employee pays for outpatient surgery or inpatient hospitilized, ER visits or for certain areas of service listed under the insurance summary plan document/certificate of coverage |
Coordination of benefits
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Eliminates the duplication of payments when the employee, spouse, or dependents have coverage under two or more plans |
| Copayment |
Usually a specified flat dollar amount that an employee must pay. For example an employee may pay a $25 copayment for a phsician office visit. |
Deductible |
Initial amount of covered medical expenses an individual must pay before receiving paid benefits under a health-care plan; usually expressed in terms of an individual and/or family deductible or a per-service fee. |
Gatekeeper |
Individual, usually a primary-care physician, who is given control of patient access to specialists and services in a managed care organization |
Lifetime Maximum Benefit
|
Maximum dollar amount of covered medical expenses that a health-care plan will pay on behalf of any covered person during that person’s lifetim.e |
Managed care |
General term for a medical plan that seeks to ensure that the treatments a person receives are medically necessary and provided in a cost-effective manner |
Medicare carve-out
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Health plan where benefits are reduced for employees eligible for Medicare; Medicare becomes the primary provider
|
Medicare supplement
|
Health plan that covers specific expenses not covered by Medicare |
Nonduplication of benefits
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Requires a secondary carrier to reimburse only up to the level of reimbursement they would have paid
|
Out-of-pocket maximum
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Stated amount out of pocket the insured can pay for medical costs in a 12-month period before coinsurance ends |
Preexisting conditions
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Medical conditions that existed before a health-care policy is taken out |
Premium sharing
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Situation in which employee pays a portion of the required monthly premium for health-care coverage
|
Reasonable and customary
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A reimbursement standard used by insurance companies to determine how much providers should be paid for their services |
Utilization review
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Audit of health-care use and charges to identify which benefits are used and to make certain that care is necessary and costs are in line |
