· Annual Limit - A benefit may be limited to a certain dollar or utilization limit (example: chiropractic care may be limited to 20 visits per calendar year).
· Alternative Funding Arrangement - A hybrid funding arrangement that features benefits of both self funding and fully insured arrangements (ASO, Minimum Premium, et. al.).
· Birthday rule - many insurance companies have adopted this rule to determine which parent is primary payer when both parents cover the same dependents. Who ever has the earlier date of birth, excluding the year, is designated primary insurance carrier. Exceptions to this rule usually arise when there is a court order for one of the parents to be the primary carrier.
· Co-insurance - Generally expressed as the percentage that you pay of any covered medical services after you have paid the deductible and co-pay.
· Co-insurance limit - The dollar amount you have to pay with Co-insurance before the insurance company begins paying your bills at 100% for the remainder of the plan year.
· Co-ordination of benefits (COB) - How your plan pays when it is coordinating with another plan. There are three principle methods in US health plans.
· Co-pay - A fixed fee you pay for services rendered. Most plans cover 100% after the co-pay for services rendered, however this can be adjusted to any amount depending on how the plan is set up.
· Deductible - The fixed amount you have to pay before your insurance starts to pay.
· Deductible carry-forward - Amounts for benefits incurred in the previous year may be subject to the prior year's deductibles.
· Employee Assistance Plan - a health-related benefit for non-medical, work-place issues or employees that commonly develop into medical issues such as marital counseling, absenteeism, suicidal ideation, etc.
· Experimental/Investigational - Most insurance companies will deny coverage for any procedures or tests which have not been medically verified by clinical trials conducted by recognized bodies of physicians or scientists. Many medical providers use tests which they believe in but have not been clinically validated.
· Fully Insured - The insurance company collects the premiums and pays claims from its own money.
· Incurred But Not Paid (IBNP) - under insurance based accrual accounting, a liability for claims that have not been paid, but may or may not be received. Incurred But Not Reported (IBNR) plus Reported But Not Paid (RBNP) equals IBNP. IBNP is a significant balance sheet item for insurers.
· In-Network/Participating/Par Providers - Medical providers who have an established relationship with an insurance company
· Life time maximum - The total your policy will pay out over the life of the contract. Many plans have a yearly restoration amount which will replenish the total so that after the policy money is exhausted there will still be some money in the following plan year for new claims. Life time maximums are easily avoided by switching policies or re-enrolling.
· Self-Insured - Many major U.S. and world corporations hire insurance companies and Third Party Administrators as claims and eligibility administrators to manage a health plan or trust. Many state laws do not apply to these plans due to ERISA exemption.
· Reciprocity - Most insurance plans deal with networks of doctors. If for example you have an HMO plan that allows you to see any HMO provider anywhere in the country, it is called Full Reciprocity, but if it only allows you access to local area networks of providers it is called Limited Reciprocity and if you can only go to select networks that your company has purchased access to, it is called No Reciprocity.
· No-fault - This is generally for automobile insurances, however if your auto policy is no-fault and you are injured, the medical insurance will become a secondary payer and will not be able to process claims until explanation of benefits are received from the auto insurance carrier.
· Out-of-Network/Non Participating/Non-Par Providers - Medical providers without an established relationship with an insurance company.
· Out Of Pocket Maximum - The total dollar amount paid out by a subscriber (deductible plus coinsurance).
· Subscriber - The primary member on the insurance policy. Also, "enrollee", "contractee".
· Reserve - refers to the amount that must be set aside for statutorily required funds for dissolution (terminal liability).
· Alternative Funding Arrangement - A hybrid funding arrangement that features benefits of both self funding and fully insured arrangements (ASO, Minimum Premium, et. al.).
· Birthday rule - many insurance companies have adopted this rule to determine which parent is primary payer when both parents cover the same dependents. Who ever has the earlier date of birth, excluding the year, is designated primary insurance carrier. Exceptions to this rule usually arise when there is a court order for one of the parents to be the primary carrier.
· Co-insurance - Generally expressed as the percentage that you pay of any covered medical services after you have paid the deductible and co-pay.
· Co-insurance limit - The dollar amount you have to pay with Co-insurance before the insurance company begins paying your bills at 100% for the remainder of the plan year.
· Co-ordination of benefits (COB) - How your plan pays when it is coordinating with another plan. There are three principle methods in US health plans.
· Co-pay - A fixed fee you pay for services rendered. Most plans cover 100% after the co-pay for services rendered, however this can be adjusted to any amount depending on how the plan is set up.
· Deductible - The fixed amount you have to pay before your insurance starts to pay.
· Deductible carry-forward - Amounts for benefits incurred in the previous year may be subject to the prior year's deductibles.
· Employee Assistance Plan - a health-related benefit for non-medical, work-place issues or employees that commonly develop into medical issues such as marital counseling, absenteeism, suicidal ideation, etc.
· Experimental/Investigational - Most insurance companies will deny coverage for any procedures or tests which have not been medically verified by clinical trials conducted by recognized bodies of physicians or scientists. Many medical providers use tests which they believe in but have not been clinically validated.
· Fully Insured - The insurance company collects the premiums and pays claims from its own money.
· Incurred But Not Paid (IBNP) - under insurance based accrual accounting, a liability for claims that have not been paid, but may or may not be received. Incurred But Not Reported (IBNR) plus Reported But Not Paid (RBNP) equals IBNP. IBNP is a significant balance sheet item for insurers.
· In-Network/Participating/Par Providers - Medical providers who have an established relationship with an insurance company
· Life time maximum - The total your policy will pay out over the life of the contract. Many plans have a yearly restoration amount which will replenish the total so that after the policy money is exhausted there will still be some money in the following plan year for new claims. Life time maximums are easily avoided by switching policies or re-enrolling.
· Self-Insured - Many major U.S. and world corporations hire insurance companies and Third Party Administrators as claims and eligibility administrators to manage a health plan or trust. Many state laws do not apply to these plans due to ERISA exemption.
· Reciprocity - Most insurance plans deal with networks of doctors. If for example you have an HMO plan that allows you to see any HMO provider anywhere in the country, it is called Full Reciprocity, but if it only allows you access to local area networks of providers it is called Limited Reciprocity and if you can only go to select networks that your company has purchased access to, it is called No Reciprocity.
· No-fault - This is generally for automobile insurances, however if your auto policy is no-fault and you are injured, the medical insurance will become a secondary payer and will not be able to process claims until explanation of benefits are received from the auto insurance carrier.
· Out-of-Network/Non Participating/Non-Par Providers - Medical providers without an established relationship with an insurance company.
· Out Of Pocket Maximum - The total dollar amount paid out by a subscriber (deductible plus coinsurance).
· Subscriber - The primary member on the insurance policy. Also, "enrollee", "contractee".
· Reserve - refers to the amount that must be set aside for statutorily required funds for dissolution (terminal liability).
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