Definitions

insurance 
Robert Nelson
Agency
724-266-0301

321 Merchant Street
Ambridge, PA 15003

724 - 266-0301 Phone
724 - 266-8677 Fax

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A

Ancillary Services - services, other than those provided by a physician or hospital, which are related to a patient’s care, such as laboratory work, x-rays and anesthesia.

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C

Calendar Year - the period beginning January 1 of any year through December 31 of the same year.

Case Management - a process whereby a covered person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner.

Certificate of Coverage - a document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company.

Claim - Information a medical provider or insured submits to an insurance company to request payment for medical services provided to the insured.

Coinsurance - The portion of covered health care costs for which the covered person has a financial responsibility, usually a fixed percentage. Coinsurance usually applies after the insured meets his/her deductible.

Consolidated Omnibus Budget Reconciliation Act (COBRA) - a federal law that, among other things, requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance has been terminated if they undergo a triggering event.

Contract Year - the period of time from the effective date of the contract to the expiration date of the contract.

COBRA - Federal law that allows employees covered under an employer sponsored group plan the ability to continue that coverage for up to 18 months and longer if certain conditions are met. The employee will retain the exact same health plan as the employer has at the time. Any changes the employer makes to the health plan will also apply to the employee on COBRA.

Coordination of Benefits (COB) - a provision in the contract that applies when a person is covered under more than one medical plan. It requires that payment of benefits be coordinated by all plans to eliminate overinsurance or duplication of benefits.

Copayment - a cost-sharing arrangement in which an insured pays a specified charge for a specified service, such as $10 for an office visit. The insured is usually responsible for payment at the time the service is rendered. This charge may be in addition to certain coinsurance and deductible payments.

Covered Person - an individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement.

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D

Deductible - the amount of eligible expenses a covered person must pay each year from his/her own pocket before the plan will make payment for eligible benefits.

Deductible Carry Over Credit - charges applied to the deductible for services during the last 3 months of a calendar year which may be used to satisfy the following year’s deductible.

Dependent - a covered person who relies on another person for support or obtains health coverage through a spouse, parent or grandparent who is the covered person under a plan.

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E

Effective Date - the date insurance coverage begins.

Eligible Dependent - a dependent of a covered person (spouse, child, or other dependent) who meets all requirements specified in the contract to qualify for coverage and for who premium payment is made.

Eligible Expenses - the lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan.

Explanation of Benefits (EOB) - the statement send to an insured by their health insurance company listing services provided, amount billed, eligible expenses and payment made by the health insurance company.

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H

HIPPA - Health Insurance Portability Act of 1996 -- Federal Law that allows a person covered under a group or individual health insurance plan the availability to convert coverage with no pre-existing condition. Coverage must be converted within 62 days of the termination of the prior health plan.

HMO - Health Maintenance Organization, a referral is necessary for care.

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I

Insured - a person who has obtained health insurance coverage under a health insurance plan.

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M

Managed Care - a health care system under which physicians, hospitals, and other health care professionals are organized into a group or "network" in order to manage the cost, quality and access to health care. Managed care organizations include Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs).

Medical Savings Account (MSA) - an account that allows you to purchase health care services tax-free. It works in conjunction with a high deductible insurance policy.

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O

Out-of-Pocket Maximum - the total payments that must be paid by a covered person (i.e., deductibles and coinsurance) as defined by the contract. Once this limit is reached, covered health services are paid at 100% for health services received during the rest of that calendar year.

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P

Participating Provider - a medical provider who has been contracted to render medical services or supplies to insureds at a pre-negotiated fee. Providers include hospitals, physicians, and other medical facilities.

Point of Service (POS) - a referral is necessary for care but will allow you to self-refer with additional out of pocket.

Pre-existing Condition - A condition that manifested itself before the effective date of your health insurance.

Preferred Provider Organization (PPO) - a health care delivery arrangement which offers insureds access to participating providers at reduced costs. PPOs provide insureds incentives, such as lower deductibles and copayments, to use providers in the network. Network providers agree to negotiated fees in exchange for their preferred provider status.

Provider - a physician, hospital, health professional and other entity or institutional health care provider that provides a health care service.

Primary Care Physician (PCP) - a physician that is responsible for providing, prescribing, authorizing and coordinating all medical care and treatment.

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R

Reasonable and Customary (R &C) - a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community.

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U

Underwriting - the act of reviewing and evaluating prospective insureds for risk assessment and appropriate premium.

* Please review your policy for each carriers exact definitions

The Robert Nelson Agency is an independent medical and healthcare insurance broker, advisor and intermediary, offering free quotations to both corporate and individual consumers. Being fully independent and not tied to any one insurance company, we are in a unique position to analyze your needs and then give you the best advice and recommendations on the right product for you at the best premium. We can also handle your health insurance requirements if you travel out of the country. We do not make cold calls but respond to your requests via emails, fax or phone. We never take clients' funds, which are paid directly to the insurance companies we recommend to you. Any remuneration to us is made from the insurance companies where we place your business.

We look forward to serving you.

Robert Nelson  
Sincerely,
Robert Nelson
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