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Health Insurance terms

Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.
Co-insurance refers to money that an individual is required to pay for services, after a deductible has been paid. In some health care plans, co-insurance is called "co-payment." Co-insurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent.
Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 "co-payment" for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.
Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For more information, visit the Department of Labor.
The amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.
Explanation of Benefits:
The insurance company's written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check.
Generic Drug:
A "twin" to a "brand name drug" once the brand name company's patent has run out and other drug companies are allowed to sell a duplicate of the original. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics.
Health Maintenance Organizations (HMOs):
Health Maintenance Organizations represent "pre-paid" or "capitated" insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided, Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician's own office (as with IPAs.)
Providers or health care facilities which are part of a health plan's network of providers with which it has negoiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
Lifetime Maximum Benefit (or Maximum Lifetime Benefit):
the maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
Long Term Care Insurance (“LTC”)
Long Term Care Insurance is a special type of health insurance that is designed to cover expenses of nursing home care, home health care or other types of defined care that persons may need at various stages of their lives, and not necessarily just at advanced ages. LTC products must have a minimum 12-month benefit period, but can have longer benefit periods. LTC benefits are frequently described as a specific dollar amount per day (e.g. $100 per day). LTC products have elimination periods, expressed in days, before which LTC covered benefits become payable after disablement. Elimination periods basically work like deductibles and represent a form of cost sharing where the policyholder agrees that LTC benefits won’t be paid for the first few days after a person qualifies for benefits under the LTC coverage. These elimination periods reduce the premium for LTC. Generally, eligibility for benefits under LTC is conditioned on a covered person not being able to perform two or more activities of daily living ( such as eating, bathing, dressing, transferring from bed, continence, etc.) and cognitive challenges such as Alzheimer’s can also qualify a person for benefits. LTC can be sold on an individual or on a group basis.

Some LTC policies are sold as Tax-Qualified Long Term Care coverage, which get some favorable federal tax treatment in premiums and/or benefits.

Still other specially designed, Tax-Qualified LTC policies are Long Term Care Partnership Qualified, meaning that they meet certain federal standards and have the potential to get favorable treatment if the holder which uses their benefits ever qualifies for Medicaid. LTC Partnership Qualified policies have potential protection for levels of assets of the policyholder to be disregarded on a dollar-for-dollar basis under Medicaid Asset Disregard standards.

Many states, including Georgia, now have this additional LTC Partnership qualification. Under Long Term Care Partnership, states have reciprocity. Reciprocity means that a person can eventually qualify for favorable consideration under Medicaid and Asset Disregard standards with his or her Long Term Care Partnership policy they have purchased, maintained and used, if they move to another state which is LTC Partnership participating. So the state in which you buy the LTC Partnership qualified policy doesn’t necessarily have to be the state you live in later in your life when you use the benefits and may qualify for Medicaid in that state. Moving around from state to state over your working life, or being moved closer to your children after you have age or retired is often the case in today’s society with families spread out more than in the past.


The following link  leads you to a chart showing the companies which have approved, certified Long Term Care Partnership products in Georgia:


Long Term Care Partnership touches on future potentials and advantages for covered persons who qualify in the future under Medicaid. Georgia’s Medicaid program is different in benefits and focus than insurance, and, by law, is outside the agency responsibilities of the Office of Commissioner of Insurance. Therefore, we refer persons interested in those potential aspects of Georgia’s Long Term Care Partnership program as they potentially relate to Medicaid to the Georgia Department of Community Health’s website HERE.
Managed Care:
A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality, by emphasizing prevention of disease.
Out-of-Plan (Out-of-Network):
This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual's insurance company.
Out-Of-Pocket Maximum:
A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.
Pre-existing Conditions:
A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.
Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.
Reasonable and Customary Fees:
The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.
The dollar amount of claims filed for eligible expenses at which which point you've paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.
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