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insurance & medical glossary
A specified payment amount required by an insurer/insurance company to provide coverage under a given insurance plan for a defined period of time. The premium is paid by the insured party to the insurer, and primarily compensates the insurer for bearing the risk of a payout should the insurance agreement's coverage be required.
A flat amount a group or individual must pay before the insurer will make any benefit payments in fulfilling the plan coverage.
Primary Care Physician - is the principle in the medical delivery system, who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis.
Preferred Provider Organization - A type of health insurance arrangement that allows insurance plan participants relative freedom to choose the doctors and hospitals they want to visit.
Health Maintenance Organization - An organization that provides health coverage with providers under contract. A Health Maintenance
differs from traditional health insurance by the contracts it has with its providers.
Under your primary care physician, a prior approval is sometimes needed in advance for a referral for other medical services. An approval is also called an "
". It is important to follow your health plan's rules about referrals and prior approval. If you do not follow the rules, you usually have to pay all of the cost of the services yourself.
A decision by your health insurer or plan may require prior to health care service, treatment plan, prescription drug or durable medical equipment, before you receive them, except in an emergency.
A 'Formulary' is a list of drugs. Traditionally, the list contained a collection of prescription drugs and its supporting function today, is to specify particular medications that are approved to be covered under a particular insurance policy.
A federal government program established to provide hospital expense and medical expense insurance to qualifying people aged 65 years and older, and are who have been deemed disabled.
An alternative to Medicare Parts A and B, in which a private company provides your primary healthcare coverage.
Medicare Part A:
Medicare insurance that pays for stays in the hospital and skilled nursing facilities, along with hospice care, and some home healthcare.
Medicare Part B:
Medicare insurance that pays for doctor's visits, laboratory test, medical equipment, and some other medical services.
Medicare Part D:
(Medicare Prescription Drug Plan - The newest part of Medicare, which provides assistance in covering prescription brand name and generic drugs.
A private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.
Is the dollar amount set by managed care organizations that limit the amount a member has to pay our of his/her own pocket for a particular set of healthcare services during a particular time period.
Electronic Benefit Transfer - Is an electronic system that allows state departments to issue benefits via a magnetically encoded I.D. Card, used in the United States and the United Kingdom. Common benefits provided (in the United States) via EBT are typically of two general categories; Food and Cash benefits. Food benefits are federally authorized and are authorized only to purchase food.
Refers to the amount of money an individual is required to pay for services, after a deductible has been paid. In some healthcare plans, co-insurance is called a "co-payment." Co-insurance is often specified by a percentage, i.e.
for service or
an employer or the insurance company will pay.
Is a predetermined (flat) fee that an individual pays for healthcare services, in addition to what the insurance covers, i.e. a $10 "co-payment for each office visit, regardless of the type or level of services provided during the visit.
A social health care program for families and individuals with low income and resources. The Health Insurance Association of America describes Medicaid as a "government insurance program for persons of all ages whose income and resources are insufficient to pay for health care.
Supplemental Nutrition Assistance Program - Offers nutrition assistance to millions of eligible, low-income individuals and families and provides economic benefits to communities. SNAP is the largest program in the domestic hunger safety net. The Food and Nutrition Service works with State Agencies, nutrition educators, and neighborhood and faith-based organizations to ensure that those eligible for nutrition assistance can make informed decisions about applying for the program and can access benefits.
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