Health Insurance for Oklahoman's

Health Insurance

Calendar Year Deductible

This is the amount of covered medical expenses the insured pays each calendar year before the insurance plan pays. There is normally a calendar year deductible for each insured. Each insurance carrier may have a different maximum deductible that a family may have to pay. Some plans may also have a separate deductible for charges incurred in a PPO network and charges incurred outside of a PPO Network.

Coinsurance

This is a percent of the covered charges that an insured will pay after he/she has met their deductible. The insurance carrier will also pay a percent of the covered charges up to a maximum coinsurance limit. The limit may vary between plan designs. As an example, an insured may have a 20% coinsurance up to $5,000. This means that the insured will pay 20% of $5,000 of covered medical expenses and the insurance company will pay 80%.  After that, the insurance company will pay 100% of covered charges.

Co pay

This is a fee the insured pays each time he/she receives certain medical services. These medical services may vary between insurance carriers, but is generally a fee you will pay for visiting a doctor, using the emergency room, hospital admission or for buying a prescription.

Covered Charges

This is an expense or fee incurred by an insured person because of injury or sickness. This expense must be medically necessary and not be excluded from coverage.  

Dependent

This is a qualified family member who may be covered under your insurance plan.  Children may now be covered up to the age of 26. 

Emergency

An emergency is subject to varying interpretations by insurance carriers, but generally means the sudden onset of a sickness or injury, that without immediate medical care, could reasonably be expected to result in death, placing the covered person in serious jeopardy, creating a serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Formulary Drug List

This is a preferred list of prescription drugs used in a health insurance plan. A formulary list is usually divided into three categories:  generic, preferred brand name, non-preferred brand name.

HMO

The Health Maintenance Organization is an organization which provides comprehensive heath care by its member physicians, referred to as primary care providers. These primary care providers will treat your medical condition or refer you to a specialist if they are unable to treat your condition.

Insured

An insured is each individual who is covered under your health plan.

Lifetime Maximum Benefit Payable

This is the total amount of benefits an insurance carrier will pay to an insured for covered charges. Some covered charges may be subject to a different lifetime maximum benefit.

Medically Necessary

This is subject to varying interpretations by insurance carriers, but generally means medical treatment or services prescribed by a physician, to the extent required to treat or diagnose an injury or sickness. The treatment or services usually means the shortest, least expensive way to treat the condition, that does not conflict with generally accepted medical standards.

Out of Pocket Maximum

This is the total amount the insured pays annually in deductibles and coinsurance of covered expenses. After this amount is met, the insurance company will pay 100 % of the remaining covered charges. Each carrier will have a different out of pocket maximum for the insured and a different maximum amount for the family.  Co-pays, non covered charges, and amounts above the lifetime maximum are not counted in calculating the out of pocket maximums.

PPO Provider

A Preferred Provider Organization is a network of doctors, hospitals and other medical service providers who agree to provide their services under a contract with an insurance carrier or third party.

Health Savings Accounts

This is a way for individuals to set aside money in an account which may earn interest that is not taxable, and withdraw these funds to pay for certain medical expenses.  Certain restrictions apply, and a health savings account is only available with certain types of health insurance plans.

Flexible Spending Accounts

This is an account set up by an employer in which an individual may have money deducted from his/her pay check before taxes and later used to pay for certain medical expenses. Certain restrictions and requirements apply.

Health Reimbursement Accounts

This is similar to a flexible spending account, but the money is put into an account by the employer.

Fee for Service Plans or Indemnity

This is a traditional insurance plan which allows the insured to select any doctor, hospital or health care provider. The plan will pay all or a share of the covered charges. These plans will typically have a deductible and co insurance.

POS or Point of Service Plans

This is a cross between an HMO and PPO. You select a primary care physician, but have the option of going to a doctor other than your primary care physician.

Reasonable and Customary Charges

This is the amount charged by health care providers or health care services which is consistent with the charges from similar providers for identical or similar services in your area. Areas may be broken down by zip codes, counties etc.

 

Affordable Care Act Uniform Glossary of Health Coverage & Medical Terms

     Click here for the Uniform Glossary

 

 

 

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