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Coinsurance
The amount you are required to pay after you have met your deductible. The coinsurance
rate is usually an expressed percentage. Example: If the insurance company pays 80% of the
claim. You pay 20%. |
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Co-payment or Co-pay
Refers to the payment that must be made at the time of service for Physician Office
Visits. |
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Deductible
Is a specified dollar amount which must be paid by the covered individual in
each deductible accumulation period before payment of benefits will be made by the
insurance company. |
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Emergency Services
Services provided within 48 hour of an injury or medical emergency. |
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Exclusions
Services provided within 48 hour of an injury or medical emergency. |
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Medical Emergency
The sudden onset of a medical condition with acute symptoms of severity that
the absence of immediate medical condition could result in: A) permanently placing the
patients health in jeopardy;
B) causing other serious medical consequences;
C) causing serious impairment to bodily functions;
D) causing serious and permanent dysfunctions to any body part; |
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Medical Necessary
Describes health care treatments, services or supplies which are appropriate
and consistent with the diagnosis and treatment of a medical condition according to
generally accepted medical standards. |
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Out-of-pocket expenses
Refers to the amount a covered person will have to
pay “Out of their pocket” in a calendar year. |
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Pre-existing condition
Condition for which a person received medical care, treatment, services,
medication, diagnosis, or consultation 12 months prior to the insured person’s
effective date of coverage or a condition that produced symptoms that are distinct and
significant enough to establish the onset of a condition or that the condition manifested
itself, where a person learned in medicine would be able to diagnose the condition because
of those symptoms. |
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Premium
The amount you pay in exchange for insurance coverage. |
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Provider
Any person (Doctor, Nurse, Dentist) or institution (hospital or clinic) that
provides medical care. |
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