TERMINOLOGY

Terminology.

In order to maximize your health insurance benefits and work with your insurance company to your advantage, it is most important that you understand what your benefits are and what the terminology means. If you work for a large company, you usually have the opportunity to change plans once a year. Do not use the dartboard method of choosing a health insurance plan. Know what you are buying and know how your plan works. This article is intended to make it easier for you to understand the health insurance market today.

ALLOWABLE EXPENSE – the allowance for charges for services rendered or supplies furnished by a health care provider that would qualify as a covered expense.

BIOLOGICALLY BASED MENTAL ILLNESS – approved diagnosed conditions such as schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. Biologically based illnesses are treated like any other medical condition.

CO-INSURANCE – the portion of the eligible charge, which is the member’s financial responsibility for out-of-network services.

COORDINATION OF BENEFITS – the practice of correlating the payments a plan makes with payments provided by other insurance covering the same charges or expenses, so that (1) the plan with primary responsibility pays first, (2) reimbursement does not exceed 100 percent of the actual expense and (3) the plan does not pay more than it would if no other insurance existed.

CO-PAYMENTS – the fee charged to a member or patient to be paid directly to the provider (primary care physician) or network specialist at the time treatment is rendered for certain covered services.

DETOXIFICATION FACILITY – a health care facility licenses by the state it is in as a detoxification facility for the treatment of alcoholism and/or substance abuse.

EMERGENCY – a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: 1) placing the health of the individual (or pregnant woman or her unborn child) in serious jeopardy, 2) serious impairment to bodily function and 3) serious dysfunction of bodily organ or part. In other words, if you are feeling blah and wish to see a doctor, that does not constitute a medical emergency requiring a trip to the Emergency Room.

HOSPICE – a provider that renders a health care program, which provides an integrated set of services, designed to provide comfort, pain relief and supportive care for terminally ill or terminally injured people under a hospice care program.

MEDICALLY NECESSARY AND APPROPRIATE – a service or supply that your insurance company determines meets each of the following requirements: 1) It is ordered by a doctor for the diagnosis or the treatment of an illness or injury. 2) The prevailing opinion within the appropriate specialty of the United States medical profession is that it is safe and effective for its intended use, and that its omission would adversely affect the person’s medical condition. 3) It is furnished by an eligible provider with appropriate training, experience, staff, and facilities to furnish this particular service or supply.

We will continue this dictionary of terminology next week.

Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.

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