Insurance

Diagnostic billing code

A 5 digit code that specifies injury/condition that is being treated

Policy

A contract between the insurance company and the insured that states the exact term of the policy including what risked are covered and how much will be paid of any losses

Claim

A form sent to the insurance company requesting payment for covered medical expenses

Health maintenance organization (HMO)

A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific, in-network plan providers.

Out-of-network provider

A health care professional, hospital, or pharmacy that is not part of a health plan's network of preferred providers. You will generally pay more for services received from out-of-network providers.

In-network provider (in panel)

A health care professional, hospital, or pharmacy that is part of a health plan's network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.

Preferred Provider Organization (PPO)

A health insurance plan that offers greater freedom of choice than HMO (health maintenance organization) plans. Members of PPOs are free to receive care from both in-network or out-of-network (non-preferred) providers, but will receive the highest level of benefits when they use providers inside the network.

Medicaid

A health insurance program created in 1965 that provides health benefits to low-income individuals who cannot afford Medicare or other commercial plans. Medicaid is funded by the federal and state governments, and managed by the states.

Policyholder

A person who owns the insurance policy

Health savings account (HSA)

A personal savings account that allows participants to pay for medical expenses with pre-tax dollars. HSAs are designed to complement a special type of health insurance called an HSA-qualified high-deductible health plan (HDHP). HDHPs typically offer lower monthly premiums than traditional health plans. With an HSA-qualified HDHP, members can take the money they save on premiums and invest it in the HSA to pay for future qualified medical expenses.

Billing code

A series of numbers used to identify what diagnosis or treatment is being applied to the patient.

Professional liability insurance

A supplemental policy that covers the insured against claims of negligence. Covers an individual for a claim of negligence in a civil case. Provides no coverage in a criminal case.

List and define the four parts of Medicare

A: Hospital portion - premium free at retirement to beneficiaries B: Physician portion - monthly premium charge C: Choice of health care plans D: Prescription coverage

Provider

Any person (i.e., doctor, nurse, dentist) or institution (i.e., hospital or clinic) that provides medical care.

Exclusion

Any specific situation, condition, or treatment that a health insurance plan does not cover.

Co-payment

One of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance company pays the rest.

Health Insurance

Provides money to pay for health care for illness, injury, or in some cases preventive care.

Life Insurance

Provides payment to beneficiaries who are named by the insured person.

Homeowners insurance

Provides payment to cover liability losses as well as damage and loss of the home structure and its contents.

Liability Insurance

Provides payment to others if a member of the insured household accidentally causes harm to other people or property.

Disability Insurance

Provides payment to replace earnings during times when workers can not work due to illness or injury

Automobile Insurance

Provides payments for both liability and property insurance on a vehicle

Long-term care insurance

Provides payments for extended nursing care due to accidents, illness, or old age.

Property insurance

Provides payments to the insured person if his or her property damaged or destroyed by an accident cover by the insurance policy

dependent

Someone who relies on someone else got income and care

Premium

The amount you or your employer pays each month in exchange for insurance coverage.

Coinsurance

The amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.

Risk

The chance of loss from an event that cannot be entirely controlled

Medicare

The federal health insurance program that provides health benefits to Americans age 65 and older. Signed into law on July 30, 1965, the program was first available to beneficiaries on July 1, 1966 and later expanded to include disabled people under 65 and people with certain medical conditions. Medicare has two parts; Part A, which covers hospital services, and Part B, which covers doctor services.

Network (panel)?

The group of doctors, hospitals, and other health care providers that insurance companies contract with to provide services at discounted rates. You will generally pay less for services received from providers in your network.

Premium

The money paid to an insurance company to purchase a policy

Out-of-pocket maximum

The most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.

Deductible

The out-of-pocket money paid by the policyholder before an insurance company will cover the remaining costs attributed to the loss

Beneficiary

The person, people, or entity designated to receive the death benefits from a life insurance policy or annuity contract

Coverage

The risks covered and amount of money paid for losses under an insurance policy.

Moral hazard q

When the act of insuring an event increases the likelihood that the event will happen.

Adjustable Life Insurance

a policy that offers the insured the option to adjust the policy's face amount, premium, and length of protection without ever having to complete a new application, or have another policy issued

Cash value

as the policy-owner continues to pay the premiums, the cash value in the policy accumulates year by year; may be used for collateral on loan, or withdraw

Continuous Premium Whole Life

most common type of whole life insurance; stretch premium payments over the whole life of the insured up to age 100

Renters insurance

provides payment to renters to cover the damage and losses of property to a rental unit in addition to liability losses

Co-insurance

requires the insured individual to pay a fixed percentage of those after the deductible has been paid.