Reso 2009-1390 - Laserfiche WebLink

Home Browse Search

SECTION X Glossary: Medical Balance Billinq: The practice of charging full fees in excess of covered amounts and then billing the patient for that portion of the bill that the payer does not cover. Breakpoint: Amount to which the plan and the participant co-insure covered expenses, after which the plan pays 100%. Capitation Fee: A fixed predetermined amount paid to a provider for each person served, without regard to the actual number or nature of services provided to each person in a set period of time. Capitation is the characteristic payment method in HMOs. Carryover Deductible: A feature whereby covered charges in the last three months of the year may be carried over to be counted toward the next year's deductible. Coinsurance: A policy provision by which both the insured person and the insurer share covered medical expenses in a specified ratio (e.g., 80%/20%), after the deductible is met. Copayments: Payments made by consumers, in addition to deductibles and coinsurance, to help finance health benefit plans. Deductible: The amount of out-of-pocket expenses that must be paid for health services by the insured before becoming payable by the carrier. Exclusive Provider Orqanization (EPO): A more rigid type of PPO, closely related to an HMO. Provides benefits or levels of benefits only if care is rendered by providers within a specific network (with some exceptions for emergency and out-of-area services). Explanation of Benefits (EOB): A description, sent to patients by health plans, of benefits received and services for which the health care provider has requested payment. Fee for Service: A method of billing for heath services, under which a health provider charges separately for each service rendered. This is the usual method of billing by the majority of physicians. Gatekeeper: The primary care provider responsible for managing medical treatment rendered to an enrollee of a health plan. Health Maintenance Orqanization (HMO): A prepaid medical plan that provides a comprehensive predetermined medical care benefit package. Inpatient: A person who occupies a hospital bed while under observation, care, diagnosis or treatment for at least 24 hours. Mandated Benefits: A specific set of benefits required by law to be provided by all insurance carriers and reimbursed under all insurance policies. Maximum Benefit: The highest annual or lifetime benefit that can be received under an insurance contract. Maximum Out-of-Pocket Payments: The maximum amount of money a person will pay in addition to premium payments. The out-of-pocket payment is usually the sum of the deductible and coinsurance payments, and does not include copayments or non-covered expenses. Medical Case Manaqement: This option, often offered by insurance companies, provides coordinators to handle high cost claims and recommends specialized care and services targeted to an individual's treatment 16