Health insurance is a type of
whereby the insurer pays the medical costs of the insured if the
insured becomes sick due to covered causes, or due to accidents. The
insurer may be a private organization or a government agency. Market-based
health care systems such as that in the United States rely primarily on
private health insurance.
According the Centers for Medicare and Medicaid Services, nearly 100%
of large firms offer health insurance to their employees. Although much
more likely to offer retiree health benefits than small
firms, the percentage of large firms offering these benefits fell from 66%
in 1988 to 34% in 2002.
Common Medical Insurance Terms
Deductible - The fixed amount you have to pay before your
insurance starts to pay.
Co-insurance - A Percentage of the claim your health
insurance pays. You insure payment to the provider and the health
insurance pays a portion.
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|Affordable Health-Dental Ins
2 Beach Dr, San Rafael, CA 415 258-0390
Insurance To Go
500 Professional Center Dr
515, Novato, CA 415 898-0584Blue Cross & Blue Shield
1556 1st St # 105, Napa, CA 707 255-9511
Sanders Jacobs Cassayre Ins
3200 Villa Ln, Napa, CA 707 252-8822
1556 1st St # 105, Napa, CA 707 255-9511
Secure West Insurance Marketing ±
951 Galleron Rd, St Helena, CA 707 967-9835
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Co-insurance limit - The dollar amount you have to pay
with Co-insurance before the insurance company begins paying your
bills at 100% for the remainder of the plan year.
Out Of Pocket Maximum - The total dollar amount paid out
by a subscriber (deductible plus coinsurance).
Co-pay - A fixed fee you pay for services rendered. Most
plans cover 100% after the co-pay for services rendered, however this
can be adjusted to any amount depending on how the plan is set up.
Life time maximum - The total your policy will pay out.
Many plans have a yearly restoration amount which will replenish the
total so that after the policy money is exhausted there will still be
some money in the following plan year for new claims.
Co-ordination of benefits or COB - How your plan pays
when it is second to another plan. There are three principle methods
in US health plans.
Maintenance of benefits - If the other plan pays the
same amount or greater than your plan, then your plan pays nothing. If
the other plan pays less, your plan pays only the difference between
what it would have paid and what the other did pay.
100% allowable - The secondary plan pays the patient
responsibility up to the full allowed amount by the plan.
Government Exclusion - In general these plans take the patient
responsibility remaining from the primary plan and treat it as a brand
new claim and pay it under the normal plan benefits.
Self-Insured - Many major U.S. and world corporations
hire insurance companies as administrators to manage a pool of money
held by the company. Many state and federal laws do not apply to these
Fully Insured - The insurance company collects the
premiums and pays claims from its own money.
Reciprocity - Most insurance plans deal with networks of
doctors. If for example you have an HMO plan that allows you to see
any HMO provider anywhere in the country, it is called Full
Reciprocity, but if it only allows you access to local area networks
of providers it is called Limited Reciprocity and if you can only go
to select networks that your company has purchased access to, it is
called No Reciprocity.
Experimental or Investigational - Most insurance
companies will deny coverage for any procedures or tests which have
not been medically verified by clinical trials conducted by recognized
bodies of physicians or scientists. Many medical providers use tests
which they believe in but have not been clinically validated.
No-fault - This is generally for automobile insurances,
however if your auto policy is no-fault and you are injured, the
medical insurance will become a secondary payor and will not be able
to process claims until explanation of benefits are received from the
auto insurance carrier.
The Birthday rule - many insurance companies have
adopted this rule to determine which parent is primary payor when both
parents cover the same dependants. Who ever has the earlier date of
birth, excluding the year, is designated primary insurance carrier.
Exceptions to this rule usually arise when there is a court order for
one of the parents to be the primary carrier.
Subscriber - The primary member on the insurance policy.
Par Providers - Medical providers who have an established
relationship with an insurance company
Out-of-Network/Non Participating/Non-Par Providers -
Medical providers without an established relationship with an
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