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Health Insurance Glosary
 
Health Insurance Glossary
   
Health Insurance Maintenance Organization (HMO)
 
• A form of managed care where an individual contracts with the plan sponsor for services through the organization in return for a monthly premium.
• The organization, in return, contracts with certain providers to perform health care services.
Managed Care  
• A medical delivery system that manages healthcare and costs through a network of physicians, hospitals and health care providers.
Point of Service (POS)  
• A form of managed care health insurance plan where the insured chooses a preferred provider from a list of physicians who have a contractual relationship with the sponsor to provide services to the member or refer them to other physicians who are a part of the plan.
• Physician is required on application.

Preferred Provider Organization (PPO)

 
• A form of managed care plan where the individual had a broad range of providers to choose from, but with negotiated rates for services.
• Physician is NOT required on application.
2 Tier  
• A rate structure that sets monthly premiums based on (a) Single person coverage and (b) Family coverage.
• A Single employee will enroll as Single. An Employee with Spouse, Employee with Children or Family (employee, spouse and children) will enroll as a Family. The 2 tier rate is ideal for Single and Family employees due to the 2 tier structures price break for family rates. If the company is set up as 2 tier and hires an Employee with Spouse or Employee with Children, they will have to pay the Family rate due to the 2 tier system.
• Medical Insurance Companies that offer 2 tier are: Atlantis Health Plan, Empire Blue Cross HMO only, GHI and HIP.
• The Single rate will remain the same within 2, 3 and 4 tier rate structures. All other rates will be affected by changing the rate structure.
3 Tier  
• A rate structure that sets monthly premiums based on (a) Single person coverage, (b) Two-Party coverage (employee and spouse OR employee and child) and (c) Family coverage.
• A Single employee will enroll as Single. An Employee with Spouse or Employee with Children will enroll as two-party. A Family (employee, spouse and children) will enroll as a Family.
• Medical Insurance Companies that offer 3 Tier are: Empire Blue Cross and HIP.
• The Single rate will remain the same within 2, 3 and 4 tier rate structures. All other rates will be affected by changing the rate structure.
4 Tier  
• A rate structure that sets monthly premiums based on (a) Single person coverage, (b) Employee and Spouse coverage, (c) Employee with Children coverage and (d) Family coverage.
• A Single employee will enroll as Single. An Employee with Spouse will enroll as Employee and Spouse. An Employee with Children will enroll as Employee and Children. A Family (employee, spouse and children) will enroll as a Family.
• Medical Insurance Companies that offer 4 Tier are: Aetna, Atlantis Health Plan, Cigna HealthCare, Empire Blue Cross, GHI, Guardian HealthNet, HIP, Horizon HealthCare, Oxford Health Plans, United Health Care, and Vytra Health Plans.
• The Single rate will remain the same within 2, 3 and 4 tier rate structures. All other rates will be affected by changing the rate structure.
Age and Gender Rated (Age and Gender Based Rates)  

• The premium is based on the overall age and gender of the groups of employees. A census of Age, Gender, Home Zip Code and Marital Status (Employee, Employee/Spouse, Employee/Children and Full Family) should be gathered from the client.

Health Insurance Portability and Accountability Act (HIPAA)  
• HIPAA is a federal act in the continuation of healthcare benefits for individuals and members of small group health plans and establishes equality between the benefits extended to these individuals and those benefits offered to employees in large group plans.
The act also contains provisions designed to ensure that prospective or current employees in a group health plan are not discriminated against based on health status.
In-network  

Refers to the use of providers who participate in the health plan’s provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee’s out-of-pocket expense.

Out-of-network  
The use of health care providers who have not contracted with the health plan to provide services. Depending on your contract, out of network services may not be covered.
In-patient Benefits  

• Charges for room and board.
• Charges for necessary services and supplies, referred to as hospital extras, other hospital charges or ancillary services.
• Typical maximum periods of hospital stay that benefits are payable, are 31, 70, 120 or 365 days.

Drug Formulary  
• A listing of prescribed drugs covered by an insurance plan.
• Generic ‚ covered under the 1st tier drug card for co-payment.
• Brand / Formulary ‚ covered under the 2nd tier drug card for co-payment.
• Non-Formulary ‚ covered under the 3rd tier drug card for co-payment ‚ this is a prescription that is not part of the health insurance company’s formulary listing.
Riders  
• Extended coverage on a contract that can increase or decrease the coverage. Some riders that can be added or taken away include: Dental coverage, Vision coverage, Private Duty Nursing, Hospital Deductibles, Skilled Nursing Facility, Mental Health Alcohol/Substance Abuse, Dependant Age and Removing Pre-Existing Conditions.
   

 

 
 
 
Gospich Advisors, LLC
Phone : (718) 674-2291 E-mail: info@gospichadvisors.com