Health Insurance Glossary

Pre existing conditions were concerns before “ObamaCare.” Previously insurance companies would refuse coverage or limit coverage when an employee had a medical condition. When a person applied for individual coverage, they would be declined. Now insurance companies enforce an open enrollment rule. There are rules for when you can enroll. Having open enrollment rules controls cost for the insurance companies. The pre-existing condition rule can still exist under certain circumstances. It is wise to ask when enrolling.

Those services which are medically required within a short time frame, usually within 24 hours, in order to prevent a serious deterioration of a person’s health due to an illness or injury.

Usual, Customary and Reasonable: A medical expense insurance benefit structure that is not scheduled, but rather is based on the fee charged by all doctors in a given geographical area.

May be called “Out of Pocket Maximum” or OOP. A maximum dollar limit set on the coinsurance, to limit the out of pocket expense that an insured can incur in a policy year. This may or may not include the deductible. Only covered expenses count toward the maximum. For example, any charges above the fee schedule for a doctor’s services do not count toward the “out of pocket maximum.”

A medical expense insurance benefit structure that lists the amount payable for each expense of a medical procedure and or service.

A California Insurance Licensed Agent for Health Insurance can either be licensed to sell health insurance by having a Life Producer License or Fire and Casualty License. Independence of submitting new business with Health Insurance Carriers depends on agent’s contracts with various carriers. Typically health insurance carriers are not as restrictive in accepting contracts with new agents as are the Property & Casualty Insurance carriers.

Preferred Provider Organization: An arrangement under which a selected group of independent hospitals and medical practitioners in a certain area, agree to provide services at a prearranged cost (a set fee for each service). The doctor or professional medical service entity is paid for services as they are given to the patient/consumer. The patient can direct refer to specialists. It is important to note that many procedures and tests still need pre-authorization from the insurance company that is sharing expense with the patient. Even though a patient does not need to have a “primary physician”, a relationship with a general practitioner is still recommended. Many specialists see patients only after they have been to a general practitioner.

An option for purchasing prescription drugs. Normally only maintenance drugs are available for mail-order purchases. A mail order purchase of prescription drugs can save money by eliminating one or two co-payments. Example: one co-payment for a 2 month supply. When taking advantage of this option, be sure to ask your doctor for the proper prescription amount. Certain conditions, such as diabetes require insulin and injection supplies that are covered differently than other medications. The mail order benefit is handled by the pharmacy plan of each medical plan. Typically the major pharmacies (Longs, RiteAid, Sav-On, Vons, etc.) do not process the mail-order forms. You will need to request a form from your insurance company upon enrollment.

This plan design is similar to the HMO plan. With this type of plan the member can self-refer to a physician who is not their primary physician. Typically the physician needs to be within the same network the member’s primary is in. The self-referred office visit is higher ($30). If the member needs lab work performed, they should have that done by their primary physician’s designated lab. Certain rules vary with this plan design. It is important to know how the plan works before using it, otherwise the member can have tests done and not have them covered. Aetna, HealthNet and Blue Shield HMO plans offer plans with this option.