Basic Terms How to calculate Out of Pocket Costs on a Hospital Stay: If you have a $2000 deductible and 30% coinsurance health insurance plan. If you have a $10,000 emergency room or hospital stay your cost would be. $10,000 - $2000 = 8000 *.30 = $2,400 + The Deductible = $4,400.00 Adverse Selection: Individuals who expect high health care costs differentially prefer more generous and expensive insurance plans: those who expect low cost choose more moderate plans Accident plans: Cover copays, deductibles and coinsurance both in and out of network as a result of an accident. Two types of accident plans exist, one is a schedule benefit based on the type of injury the second pays benefits based on coordination or non-coordination with your health plan up to the benefit purchase. A non-coordinating accident plan is typically more expensive because you can profit from the benefits received. Balance Billing: Charges incurred when using non-network providers over and above the usual customary and reasonable allowance paid on the health plan. In PA most individual and small group plans pay at the Medicare allowance which results in a high percentage of balance billing. Benefits Vault: A new system to pay individual bills from a direct deposit of a participant s payroll. The convenience of payroll allocations directed to pay for individual products that would be typically billed to the employees home. Lapse protection option available and employers can avoid reconciliation and can give defined contributions to the purchase of plans. Brand Name Drugs: Prescription drugs that typically have a generic alternative. Non preferred brand name drugs typically have no generic alternative and have the highest cost. Catastrophic Health Plan: If you are under age 30 or have extreme financial hardship you may be eligible for catastrophic. Typically catastrophic plans have the highest deductible and the lowest premium offered by an insurance carrier. Copayment: The amount you must pay for each medical visit to a participating doctor or other healthcare provider, usually at this time service. Coinsurance: The percentage of a covered charge that you are responsible for. For example, if you have 20% coinsurance, your plan pays 80% of the covered charges. Typically you must meet a deductible prior to the coinsurance being applied. Cost Sharing: also known as out-of-network costs, this is the money you pay when you receive care in the form of the co-pay, deductible or coinsurance. This is separate from the monthly premium you pay to be a member of the health plan. Deductible: The amount of covered charges you must pay here before benefits are paid by your plan. Some services such as doctors and prescription are subject to a copay without a deductible. Embedded Deductibles: benefits kick in for a family member when one meets the individual deductible and for the whole family when at least two members. Non-embedded deductibles kick in on single contracts when meeting the deductible however, if there are more than one covered person on the same contract the higher deductible has to be met before benefits start. Non-embedded deductibles are typically used on health savings accounts, but thanks to the Affordable Care Act they are beginning to be used in other type plan.
EPO: Stands for exclusive provider organization. This is a network of doctors, specialist and hospitals that agree to accept the insurance companies contractual payment as payment in full in addition to a members copay, coinsurance or deductible requirements. Depending on the plan you choose, you may need to select a PCP who will coordinate your care and make referrals to specialists when needed. Except for emergency or urgent care, out of network care is not covered. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. FSA: flexible spending accounts allow individuals to set aside money on a pretax basis to cover his noncovered medical dental and vision expenses. In 2015 the max allowances by an employee his $2550.00. Employers can contribute with no limitations. Other limitations apply. Generic Drugs: Is a drug defined as a drug product that is comparable to a brand/referenced listed drug product in dosage form, strength, quality and performance characteristics and intended use. These typically are the least costly form for a particular medication. HMO: Health Maintenance Organizations require members to go to a primary care physician before seeking services at a specialist. These are closed network type plans with the exception of emergency and urgent care, you will not be covered using non-participating provider. Hospital Indemnity Plans: Reimburses deductibles co-pays associated with hospital related expenses that are not paid by health insurance. In proper combination with lower cost health plan a member can achieve platinum level coverage at reduce overall costs. HRA: Health reimbursement accounts are established by employers to self-insure specific medical dental and vision expenses for employees. HSA: the abbreviation of health savings account are set up by individuals that purchase high deductible health plan in place tax deductible funds into an account for tax-deferred accumulation and to pay expenses not covered by the high deductible health plan. Caution should be made to members with dependents electing this plan because the family deductible not the individual deductible has to be met before benefits are paid. In-network: doctors, hospitals, labs and other healthcare providers who contract with the health insurance carrier to deliver services to members. They usually charge discounted rates for their services. Integrated Benefits: An example of integrated benefits is when Pediatric Vision and Dental is included with the health plans. Many carriers will show the added cost separately, but will not allow you to delete the cost however; some carriers will allow you to delete these benefits if you can show the required benefits are being implemented through another carrier. Maximum-Out-Of-Pocket (MOOP): This is the most you must pay for covered health care services during the calendar year. Once you have reached your out-of-pocket maximum, your plan pays 100% of covered cost for the rest of the year. In 2015 the maximum MOOP allowed on all group or individual plans is $6,400 per person and $12,800 per family which is indexed to increase each year based on the consumer price index. Medicare Allowance: Claims payments for non-contracted doctors are based on the lesser of the Medicare professional allowable payment for the actual charges of the provider. This is a lower reimbursement than what was commonly called Usual, Customary and Reasonable (UCR).
Member: Insured or cover dependent Navigator: Assistors paid by the government to expand health care coverage to individuals in Medicaid, CHIP (Family Care) and individual plans. Navigators are not licensed nor can they give advice to members on the health insurance plan elections. Out-of-Network: doctors, hospitals, labs and other healthcare providers who do not have a contract with that a health insurance company. Members typically pay more for services from out of network providers. Balance billing can occur if they do not accept the usual customary and reasonable rate paid by the insurance company. Premiums: What you pay each month for health insurance coverage. Patient Centered Care: Your care is coordinated by your patient centered doctor, along with a team of health professionals closely monitor your health and respond to you specific needs. Valued based payment systems commonly used to rewards providers based on outcome and expansion of wellness to reduce medical expenses. One stop medical services with primary, specially, diagnostic and pharmacy services at one location. Primary Care Physician: this is just another term for your family doctor. POS Plan: Point of Service Plans are HMOs with sleep insurance. They allow out of network coverage subject to a large deductible and coinsurance using non-network providers and facility. Typically the reimbursement levels paid to non-network providers are insufficient resulting in balance billing. The availability of these plans is limited and can cause claim payment errors. Pre-certification: Requires your physician to obtain approval before the services are rendered to ensure that they meet guidelines following generally accepted medical practice. Pre-Existing Conditions: All Affordable Care health plan requires that pre-existing condition are covered. The pre-existing condition limitation will deny benefits being paid. Most supplemental sickness plans have a preexisting condition limitation for one year if the participant had a condition within the last year prior to the plans effective date. The limitation is waived provided the participant remains treatment free for one year or if treatment continues (i.e. Ongoing prescription, doctors visits) the plan will cover the condition after two years. Premiums: What you pay each month for health insurance coverage. This is separate from the co-pays, deductibles, and coinsurance you pay when you need care. It also does not count toward satisfying your MOOP. Preventive Care: Services that help you stay healthy and may also detect some diseases in the early stages. Examples include flu shots, mammograms, cholesterol test and colonoscopy. Referrals: Also called non-gated plans or open access plans, require members to see a primary care physician before going to a specialist. Annual checkups by women to an OB/GYN typically do not require a referral. Special Enrollment Event: A time outside of the open enrollment period during which you and your family have a right to sign up for health coverage. In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage. Job-based plans must provide a special enrollment period of 30 days. Specialty Drugs: drugs that typically require special handling, administration or monitoring. It s also more likely they ll need special approval to order and you may have to order them to a specialty pharmacy. This is a special tier in many prescription plans sometimes requiring a deductible, coinsurance and precertification or authorization to obtain.
Subsidies: Available to individuals not offered group health insurance through work to offset premiums if the family income is less than 400% of the federal poverty level. Individuals and families also get reductions in cost sharing in addition to premium savings if they earn less than 250% of the federal poverty level. Participants that are in less than 138% of the poverty line are eligible for Medicaid. Telemedicine: A service allowing for 24/7 access to a doctor or nurse to answer questions and diagnosis general illnesses by phone, video and email and prescribe prescriptions when necessary in the hope of reducing emergency and urgent care use. Tiered Plans: HMO providers are tiered based on cost and quality measures to provide services at lower costs. While all of the doctors and hospitals in your network must meet quality standards, many won t for the same services at a lower cost. If they cost less, then you ll pay less. Your health plans reward members to use services from tier 1 providers. Note that there is no discount when using a higher tier facility when taken by ambulance or an emergency.
1 Stop Benefits, Inc. 1546 Old Farm Court Yardley, PA 19067 www.onestopbenefitsexchange.com Phone: 1-800-662-3982 Fax: 1-888-662-3920 Date: Information required in blue fields is not needed until you enroll. Red Required EMPLOYEE INFORMATION Company Name: New Revised Main Phone: No.: Employee Name: Address: State/Province: Zip/Postal Code: SS Number: Home Phone: E-mail Address Cell Phone: Employee Status Date of employment: Job title: Modified Family Adjusted Gross Income: You Can Now Have A Personal Consultant When Needed. Allow us to customize a proposal giving you financial protection from accident and sickness on an individual basis. Consider the 1 Stop Benefits Basic Four Program with any individual or group health plan giving you first dollar coverage! Consult-A-Doc Plus Accident Plan Programs of Interest: Accident Protection Annuity / Retirement Cancer Protection Hospital Indemnity Lump-sum Critical Illness Tax Filing Status: Married Head of Household Total # of Dependents Do you smoke? yes no Driver's License number: State of Issue: Date of Birth: Birth State: Height: Weight: Critical Illness Protection Dental Protection Health Protection Hospital Indemnity Life Insurance Long Term Care Legal & Identity Theft Medical Reimbursement Spouse Date of Birth: Does your Spouse smoke: Spouse Birth State: Height: Weight: For insurance purposes only, list all dependants Medicare Supplements Pet Insurance Telemedicine "CADR-Plus" Special Needs: Name Social Security No. Birth Date When submitting this form for quotes do not send Social Security Numbers. They will be needed for actual enrollment. If any child smokes please indicate who in the special needs box above.