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Health InsuranceDefinitions
Assignment of Benefits
A member signs a form to give the insurance company permission to directly pay the provider.
Claim
A request for payment by a medical provider for a service rendered.
COBRA
Allows an individual to remain on the group plan of their past employer (A group of
20 or more) for a period of time.
Conversion Plan
When an individual changes from a group plan to an individual plan.
Co- payment
A form of medical cost sharing that requires an insured to pay a fixed dollar amount when
medical services are received.
Covered Expenses
Services that the insurance company agrees to pay for.
Deductible
A fixed dollar amount that the member pays before the insurance company starts paying for
medical expenses.
Exclusion
Medical services that are not covered by an insurance plan.
Maximum out-of-pocket expense
The maximum dollar amount a member is required to pay out of pocket during a year.
Medically Necessity
Services or products that are needed to for the diagnosis, care, or treatment of a medical condition.
Maximum Out of Pocket Expense
The maximum amount of money that a member has to pay in a given year for deductibles and co-insurance.
Participating Provider
A physician or other medical provider that has agreed to accept a set fee for the services provided
to the member of a specific plan.
Pre-Existing
A medical condition diagnosed prior to the effective date of the health plan.
Waiting Period
The time that is required to wait before a member is eligible for coverage.