Common Reimbursement Terms
General Insurance Terms
Co-payments
Co-payments are a sum of money that you pay each time you receive a service or product from a healthcare provider. For example, you might be charged a $15 co-payment for a visit to your physician, while your insurance company will pay the balance. Check your plan to see the amount of co-payments and deductibles required.
Deductible
Your deductible is the total amount of money you need to pay before your insurance plan begins paying its share of costs. For example, you may have a $250 deductible for hospitalization. You are obligated to pay the $250 before your insurance company will pay for any additional amounts you may incur for hospitalization.
Fee for service
A fee-for-service, or traditional, plan uses a method of charging in which a physician or other health-care professional bills for each office visit or service provided.
HMO
A Health Maintenance Organization (HMO) is an organization of healthcare personnel and facilities that provides a comprehensive range of health services to an enrolled population for a fixed sum of money paid in advance for a specified period of time. These health services include a wide variety of medical treatments and consults, inpatient and outpatient hospitalization, home health service, ambulance service, and sometimes dental and pharmacy services.
POS plan
POS means Point of Service plan, and it incorporates features of HMOs and PPOs. Patients are enrolled in an HMO but are offered the option to go outside the network for an additional cost.
PPO
A Preferred Provider Organization (PPO) is a group of physicians and/or hospitals that contract with an employer to provide services to their employees. In a PPO, the patient may go to the physician of his/her choice even if that physician does not participate in the PPO, but the patient receives a lower benefit level usually through higher deductibles and co-payments.
Public payers
Public payers are funded by government entities, and include Medicare, Medicaid, CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), and state high-risk insurance pools.
Referrals
Referrals are a form of authorization by your managed care plan or primary care physician. Some insurance policies may require referrals for additional treatment and coverage. Ask your insurance provider whether physician visits, laboratory analyses, or WinRho® SDF infusion require a referral.
"Transition of care" benefit
This benefit allows you to continue seeing a physician for a diagnosis even after your plan changes. For example, if your current plan allows you to see your primary physician and you transition to a new plan to which your current physician does not belong, you may be covered for seeing your physician for a specific amount of time if your employer offers the “transition of care” benefit.
Deciphering Your Insurance Plan
Following is a quick guide to how your insurance plan works.
Basic Medical Plan
Provides coverage for hospital/surgical/physician services. Also referred to as the “first part” of an insurance plan.
Medical Insurance
Offers broad coverage of most medical expenses up to the maximum benefit, offered to both group and individual insurance plans. These plans usually have deductibles and co-insurance.
Supplemental Medical Insurance
Covers those expenses not otherwise covered by the basic medical plan. Covers services at a set percentage once the beneficiary has met the deductible designated by the policy. Examples of supplemental insurance include vision and prescription.
Comprehensive Medical Insurance
The most common plan available under group health insurance. This type of plan combines both basic and major medical and pays for approved services after a deductible has been met.
Governmental Help
Following is information on legislation passed by the U.S. government that can help in your exploration of insurance coverage.
HIPAA (Health Insurance Portability and Accountability Act) AKA Kennedy/Kassebaum Act
Enacted in 1996, it helped ease the burden “pre-existing condition clauses” caused. HIPAA guarantees individual health coverage under certain circumstances when you lose group health coverage and prohibits group health plans from discrimination due to your medical condition. For more information on HIPAA, call 1-888-700-7010.
The Consolidated Omnibus Budget Reconciliation Act (COBRA)
States that employers who sponsor group health insurance plans must offer a continuation of coverage to employees and their families under certain circumstances (if hours of work have been reduced and thus employee no longer qualifies for health benefits, or if employment has been terminated for reasons other than gross misconduct). The employee has 62 days to accept or decline COBRA, and must pay the entire premium on a timely basis.
Supplemental Security Income (SSI)
Provides cash benefits to the aged, blind, and disabled, and can be applied for through your local Social Security office. Children with impairments that hinder them in school but which may not hinder them in later life are sometimes eligible for SSI.
