The Lingo
A fixed amount our patient is responsible for each visit.
Co-payment
Delivers all health services through a network and typically has lower out-of-pocket expenses. Typically, HMOs don't have deductibles and all of them require referrals. Patients can only see in-network doctors.
HMO
Applies to our patients who have more than one insurance plan
Subscriber Rule
The amount our patient pays for health insurance every month.
Premium
A plan that comes with a deductible but provides greater flexibility. A patient will typically have co-insurance and the deductible will be lower if a provider is in network.
PPO
The amount our patient pays before their insurance plan starts to pay.
Deductible
A hybrid of an HMO and a PPO. A patient can choose whether to use HMO or PPO services.
POS
Determines when a plan is primary or secondary for a dependent child when covered by both parents’ benefit plan
Birthday Rule
The total amount (inclusive of patient liability) that the health plan has agreed should be paid for a healthcare service under the terms of the plan
Allowed Amount
Healthcare provider for veterans. To qualify for VA benefits, generally one must have a military service related injury or illness. Services must be provided at a VA facility unless authorized by or unavailable at a VA facility.
Veteran’s Administration (VA)
Health insurance from our patient’s employer.
Group Health Plan
A workers’ compensation program underwritten by the Department of Labor which offers coverage to individuals who became sick (developed black lungs) from working in coal mines.
Black Lung
Applies to dependent children of divorced or separated parents without a divorce decree
Custody Rule
Our patient’s share of the cost of a visit; calculated as a percentage of the allowed amount.
Co-insurance
Healthcare program that assists low-income families or individuals. (Traditional)
Medicaid
Group of healthcare providers that provide a contract price to a health insurance plan’s members.
In network
Benefit program for the families of a veteran with 100% coverage of service connected disability and the surviving spouse or veteran who dies from a service connected disability.
Civilian Health and Medical Program of the VA (CHAMPVA)
Applies to the health insurance plan subscriber and the subscriber’s dependents
Subscriber/Insured
The insurance that pays third if there are costs the primary and secondary didn’t cover.
Tertiary
Healthcare program that assists low-income families or individuals. Plan is administered through managed care organizations (MCOs).
Managed Medicaid
The highest amount our patient pays in a year before insurance covers 100%. Some policies may require a member to continue paying co-payments after the OOP is met.
Out-of-Pocket Max
Health insurance program for people who have worked in the U.S. and paid FICA taxes and who may be entitled based on certain criteria and has 4 parts.
Medicare
The payer of last resort
Medicaid
Fee for service. Allows our patient to visit almost any healthcare provider and insurance pays a set rate.
Indemnity
Coverage for patients whose injuries are caused and covered by another party
Third-party Liability