HELPFUL INSURANCE GLOSSARY TERMS
Major Medical Health Plan: Term used to describe primary and comprehensive health coverage and meets insurance and state requirements. Medical GAP Plan: Supplemental and sometimes referred as secondary medical insurance coverage that helps pay for covered medical expenses you incur using your major medical plan for in-patient hospital or out-patient settings (diagnostics, urgent or emergency care, etc) as defined by the medical plan. Deductible: The annual amount you and your family pay for healthcare services before the plan begins to pay. Calendar Year Plan: Benefit plans in which the deductible and out-of-pocket accumulators reset each January. Prior Authorization or Precertification: Applies to certain complex medical treatments or prescription drugs that require approval from the medical carrier before you receive care. In-network providers file these requests on your behalf. Out-of-Pocket Maximum: The maximum annual amount you and your family must pay for eligible healthcare expenses. Deductible, copays, and coinsurance (if applicable) accumulate towards this limit. Once met, the plan pays 100% of covered medical expenses for the remainder of the calendar year.
Copayment (Copay): A flat dollar amount you pay for medical services or prescription drugs regardless of the actual amount charged by your doctor. Copays accumulate towards your plan’s out-of-pocket maximum but do not apply towards the deductible.
Inpatient: Services provided during an overnight hospital stay.
Outpatient Services: Treatment provided at a hospital without an overnight hospital. Also includes various medical services such as diagnostic tests, treatments or procedures conducted in an outpatient facility. In-Network Benefits: Healthcare providers that have set contracted rates with the insurance company and has agreed to accept the plan. When you use in-network providers, you pay less for services because the plan pays a higher percentage of covered expenses.
Out-of-Network: Health care providers that are not contracted or participate in a plan’s network.
Specialty Drugs: High-cost prescription medications used to treat complex and chronic conditions that require precertification.
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