Glossary Of Insurance Terms

Aggregate Deductible: A combination of expenses met collectively by all family members Imbedded Deductible: Expenses of a family policy met by only one or two members of a family policy

Co-Insurance: Once the deductible is met, this is the portion that is shared by the client and the insurance company. It is the difference between the deductible and the maximum out of pocket. Usually an 80/20 or 70/30 split. The lower number or percentage is what the client is responsible for. For example if the medical bill is $2000 , and the deductible is $1000, and the co-insurance is 80/20, your client would owe , $1400.

Census Form: Used to submit for premium estimate.

Claim: The charge by the physician, pharmacy, hospital, or clinic for services rendered.

Cobra: The continuation of your health insurance policy with your employer post employment. This coverage will be terminated after 18 months. (SEE COBRA INFO BELOW)

Contracted Rate: The rate or fee you pay that has been pre-negotiated. This fee is pre-determined, and is the amount of money the Insurance company pays the physician, pharmacy, hospital or clinic.

Co-pay: The flat fee you pay for specific areas of the policy, where the deductible does not apply. For example: $30 Physician Visit, $50 Preventative Care, $50 Urgent Care, Medication: $10 Generic, $35 Brand, $55 Non Brand.

Decline: When an application has been denied by the health insurance company due to health issues.

Deductible: The financial exposure at the bottom of the spectrum or policy that the prospect will be responsible for , before the benefit begins. This does not include co-pays. This applies to PPO policies.

E and O Insurance: Errors and Omissions Insurance. This is insurance that protects the broker/agent/producer in case of legal liability due to error when handling/dealing/insuring prospect or client.

Effective Date: The date your policy begins.

EME: Estimated Medical Expense, or Usual and customary fee or charge for a procedure or service.

ER: Emergency Room

Global Billing: An all inclusive pre-determined rate. All OB (Maternity) providers submit their claims at the time of delivery and are paid a global fee.

Grace Period: Period of time given by insurance company to allow client to pay the monthly premium. If client does not pay premium within the grace period, which is usually 30 days, then the prospects coverage will be terminated on the last day of the month when premium

Group Insurance: Insurance for a group of at least two persons that are a business. This is a BUSINESS or COMPANY policy. Prospective company will need quarterly wage and tax information on associates.

Guarantee Issue: Every applicant is approved for health insurance no matter the health condition. HiPPA and Group would apply.

Health Insurance License: Need to obtain to sell health insurance in a given state.

High Risk Pools: Program provided by certain states for the un-insurable. "This can be a life saver" for those people.

HIPPA: A signed release by person that allows physician, pharmacy, hospital, clinic or any medical provider to share person's personal health history or records.

HIPPA: Guarantee Issue health insurance once you have 18 months of continuous Cobra coverage. You must have a certificate or proof of 18 months of continuous coverage , and you have 63 days to get the HIPPA insurance. If you are one day late, you will not get the insurance.

HMO: Health Maintenance Organization

In Network: Physicians, pharmacies, hospitals and clinics that the insurance company is contracted with.

Individual Application/Policy: Health Insurance policy, program or application for individual, husband and spouse, male applicant and children, and female applicant and children.

Maternity Waiting Period: A period that begins on the effective date of coverage. Can be 12 months. Plans vary.

Maximum or Lifetime Benefit: The total amount the insurance company will pay.

Maximum Out of Pocket: The total financial exposure a client has with their policy.

MIB Report: Medical Information Bureau. Contains and documents your personal medical history.

Non-Residence Health Insurance License: This is a license you can obtain from a state other then your home state and allows you to sell health insurance in THAT state. You do not have to pass a test, assuming you are licensed in your home state. You will have to pay a fee, and can do it on-line. You then mail in the proper forms, and documentation.

Out of Network: Physicians, pharmacies, hospitals and clinics that the insurance company is NOT contracted with.

PPO: Preffered Provider Organization

Pre-Existing Condition: When a prospect has a health issue or condition that has occurred prior to seeking health coverage and has been documented. This applies to the last 5 years with most insurance companies.

Premium: The monthly fee a prospect will pay for the health insurance.

Prior Authorization: Physician or physician office, will need to call in to insurance company for authorization for medication or procedure BEFORE approval.

Rate Up: When an insurance premium for a prospect is increased by the insurance company after going thru underwriting.

Rider: An addition too coverage in a policy that in most cases also increases the premium.

Underwriting: The group of people who review a prospects insurance application for approval.

UR: Urgent Care

Waiver: When a prospect has a pre-existing health issue that will NOT be covered by the insurance company for a defined period of time.

Write-Off: All monies billed by the physician, pharmacy, hospital or clinic that are more then the contracted rate. The difference is "written off", as the client or insurance company only pay the contracted rate.