Below are terms you might encounter in your insurance contract:
Allowed Amount: The maximum amount payable for covered services by your Company (Insurance Company) as set forth in your medical policy.
Coinsurance: The percentage share payable by you on claims that your company provides benefits for at less than 100% of the allowed amount.
Copay: The amount you are required to pay for certain services and supplies provided under your plan. You are responsible for the payment of any copay directly to the provider at the time of service.
Company: The Insurance Company you have entered into a Group Medical Coverage Agreement with and have been issued a Medical Policy.
Covered Services: The services for which you are entitled to coverage as set forth in your medical policy.
Deductible: A specific amount you are required to pay for certain covered services before benefits are paid by your Company. Your deductible amount is set forth in your medical policy.
Dependent: Any member of the Subscriber’s family who meets all applicable eligibility requirements, is enrolled on the medical plan, and for whom the premium has been paid.
Emergency: The sudden, unexpected onset of a Medical Condition that, in your reasonable judgment, is of such a nature that failure to render immediate care by a licensed medical provider would place your life in danger, or cause serious impairment to your health.
Group: An employer, union, welfare trust, or bona-fide association, which has entered into a Group Medical Coverage Agreement with a Company.
Lifetime Maximum: The maximum value of benefits provided for Covered Services as set forth in your medical policy after which your Company will no longer pay benefits.
Medically Necessary: Appropriate and clinically necessary services as determined by your Company. The fact that a service or supply is furnished, prescribed, recommended or approved by a physician or other provider does not make it medically necessary.
Out-of-Pocket Limit (Stop Loss): The maximum amount of Out-of-Pocket expenses incurred and paid by the subscriber and/or dependents in a calendar year for Covered Services.
Participating Provider (PAR): A provider whose name is included in the current list of participating providers with your Company and who has entered into a current Participating Agreement with the Company.
Preferred Provider (PPO): A provider whose name is included in the current list of preferred providers with your Company and who has entered into a current Preferred Plan agreement with the Company.
Primary Care Provider (PCP): Your licensed contracted medical provider who provides primarily most of your services and family care and issues your referrals.
Referrals: A prescribed note from your Primary Care Doctor recommending you seek treatment, services or supplies from another licensed provider because of a diagnosis out of your PCP’s scope of practice.
Service Area: Counties in Washington State as designated by your Company.
Subscriber: A person employed by or belonging to the Group who meets all applicable eligibility requirements, is enrolled on the medical policy and for whom all premiums have been paid.
TYPES OF MEDICAL PLANS
Point-of-Service Plans (POS): Utilizes a specific network of licensed contracted providers set forth by your Company where your Primary Care Physician (PCP) manages your care and issues referrals for all other services or supplies needed out of the PCP’s scope of practice.
Preferred Plans (PPO): Utilizing the Preferred Provider Organization list of doctors for Covered Services provided by your Company for the highest level of benefits to be paid.
Health Management Organization (HMO): Utilizes only a specific network of contracted providers in order for any benefits to be paid by your Company.