Everything you need to know about health insurance
What is a beneficiary?
The person(s) who receives the payment of the amount of insurance after the death of the insured.
What is a claim?
An application for benefits provided by an insurance company. You must first file an insurance claim before any money can be disbursed to the provider. The insurance company may or may not approve the claim, based on their assessment of the situation.
What is COBRA continuation health coverage?
The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions was created to provide certain former employees, spouses, and dependent children the right to continue health coverage for a temporary period of time.
What is co-insurance?
A specified percentage of the cost of treatment that you pay for covered medical expenses after a deductible has been paid.
For example, if you sign up for a plan that pays 80% coinsurance, the plan will pay 80% of the cost. That means that if you receive $100 in covered services after your deductible is met, the plan will pay 80% of the cost, or $80. You will have to pay the 20% remaining, in this case, $20.
What is a co-payment (copay)?
An up front fixed dollar amount you’ll pay to the doctor’s office at the time of your visit. Your co-pay benefit continues until your benefit plan’s maximum is reached. Many plans have co-payments in place for services such as doctor's visits, prescription drugs, and hospital stays.
What is a deductible?
The amount you pay for medical services before your insurance starts paying its share of your costs. Your deductible is reset on a yearly basis.
Who qualifies as dependents?
Either a spouse and/or unmarried children (whether natural, adopted or step) of an insured person. There are specific age limits that may vary from state to state.
What is an effective date?
The date your insurance is to actually begin. You are not covered until the policy's effective date.
What is an Employee Assistance Programs (EAP)?
An EAP are mental health counseling services that are sometimes offered by insurance companies or employers. The program may include access to a 24-hour nurse line, mental health assistance, and a health information library. Typically, individuals or employers do not have to directly pay for services provided through an employee assistance program.
What is an Explanation of Benefits (EOB)?
After you visit your doctor you’ll get an explanation of benefits outlining what services you received, how much those services cost, and how much your insurance paid. Review your statements closely so that you can understand the charges and your responsibility.
What is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) was created to protect private health care information and create a uniform standard for personal information.
What are inpatient benefits?
Services that require being admitted to the hospital and an overnight hospital stay. Examples of inpatient benefits include maternity and additional coverage for surgery. Services that do not require an overnight stay are referred to as outpatient benefits.
What is a limited-benefit health plan?
Starbridge limited-benefit health plans, offered by CIGNA HealthCare, are designed to provide affordable health insurance to hard-working people like you. Starbridge provides coverage for everyday medical expenses and can help you plan for unexpected expenses due to illnesses and accidents. It is not a major medical plan.
What is the maximum plan dollar limit?
The maximum amount payable by the insurance company for your covered expenses for the insured and each covered dependent while covered under the health plan.
What is a network?
A network is a group of doctors, hospitals and other health care providers contracted to provide services to insurance company’s customers for less than their usual fees. Insured individuals typically pay less for using a network provider.
What is a network discount?
The discount you receive for visiting a health care doctor or hospital who participates in a doctor discount network.
What is Open Enrollment (OE)?
A period of time where you can enroll in health benefits or make changes to your benefits.
What are outpatient benefits?
Refers to services that do not require an overnight stay in a hospital or other healthcare facility. Examples of outpatient benefits include: doctor office visits, preventive care, lab work, x-rays, and urgent care. Services that require an overnight stay are referred to as inpatient benefits.
What are out-of-pocket costs?
Out-of-pocket costs include premiums, co-payments, co-insurance, deductibles or other fees that you are required to pay outside of your health plan.
What does over usual & customary mean?
An amount by which the submitted charge exceeds the average amount charged for the same services within your health care doctor’s geographic area.
What is a pre-existing condition?
An illness, disease or condition an individual has at the time of enrollment in a health care plan.
What is a premium?
A premium is the fee you and/or your employer pay to your insurance company to purchase a health insurance plan. This can be paid on a monthly, quarterly or annual basis.
What is a primary care physician (PCP)?
A physician who serves as your primary contact within the health plan. In a managed care plan, the primary care physician provides basic medical services, coordinates and authorizes referrals to specialists and hospitals.
What is a provider?
Used for professionals who provide health care services. It typically refers to doctors, but can include nurses, physical therapists, counselors and other medical specialists.
What is a referral?
When your primary care physician sends you to another doctor, usually a specialist, for treatment or consultation.
What is reinsurance?
The acceptance by one or more insurers of a portion of the risk underwritten by another insurer that has contracted with an employer for the entire coverage.
What is a Summary Plan Description (SPD)?
A document provided by the by the plan administrator that includes a plain language description of important features of the plan such as when employees begin to participate in the plan, how service and benefits are calculated, when payment is received and in what form, and how to file a claim for benefits.