The People
Subscriber
Who is- The Policy holder. (Usually responsible for the Premiums / Employee.)
What is an HMO?
What is- Requires a PCP and referrals / Authorizations, with no out-of-network coverage except emergencies.
What is a premium?
What is- The monthly amount paid to keep coverage active.
Primary Care Physician (PCP)
Who is- The doctor who coordinates your care and provides referrals in an HMO.
Member ID
What is- The unique number identifying a member on their insurance card.
Dependents
Who is- a person who enjoys the insurance benefits and may include a Partner/ spouse and or children.
What is a PPO?
What is - Can see specialists without a referral and get some out-of-network coverage. May not need to have an assigned PCP.
Copayments
What is- A fixed dollar amount paid for a covered visit or service.
Specialist
what is- In an HMO, a referral from your PCP is required to see one of these. They treat specialized issues.
Group Number
What is- The number identifying the employer or group plan.
(actually, not on card)
Member
Who is- anyone that enjoys insurance benefits including the subscriber and/ or dependents.
What is an EPO?
What is- Network-based like an HMO, usually no referral needed, but no out-of-network coverage.
Deductibles
What is- The amount you pay for covered services before the plan begins to pay.
Prior Authorization
What is- The approval a plan must give before certain services or scans are covered.
Benefit Year
What is- The 12-month period after which benefits and the deductible reset. Usually Calendar or Plan year
The Plan
What is- a specific Set of benefits offered to members.
What is a POS?
What is- A hybrid plan needing a PCP but allowing out-of-network care at a higher cost.
Coinsurance
What is- The percentage of a covered service's cost you pay or after the deductible is met (20% = 80,ins/20,member).
Network
What is- The group of doctors and facilities contracted with the plan.
Formulary
What is- The list of prescription drugs a plan covers.
Rx info is on the reverse of the card.
Payor
What is- the Insurance Company that sponsors the benefit plans
What is Capitation?
What is- A payment model where a provider is paid a fixed amount per member per month.
Out of Pocket Maximin (MOOP)
What is- The most you'll pay in a benefit year before the plan covers 100%.
Out-of-Network care
What is- Care received from a provider not contracted with your plan.
Explanation of Benefits
What is- The statement showing what the plan paid and what you owe — and it is not a bill.