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A Word or Two From The Glossarist…

We have been tossing about all sorts of health insurance terms over the past few days.  In the interest of consumer protection, our resident insurance-speak victims support group advocate and translator would like to offer some clarification:

A Brief Glossary of Health Insurance Terms

  • Agent: A person licensed to sell insurance.  He or she might work alone or with a large firm and may sell all sorts of insurance; some agents work as employees of an insurance company and sell plans from just that company.  Make sure your agent is licensed to sell health insurance, by the way.
  • Carrier: This is another name for ‘insurance company’.
  • Claim: A request for payment of benefits received, or services rendered.  A billing record is generated and submitted by a provider or a plan subscriber, using electronic or paper media.
  • Co-insurance: A cost-sharing arrangement, under which an insured pays a fixed percentage of the cost of medical care after the deductible has been paid. For example: with an 80/20 plan, the insurance company pays 80% of the allowable charge, while the insured pays the remaining 20%.
  • Conversion privilege: The right given to an insured to change insurance without proof of insurability; usually this applied to a person seeking individual coverage upon termination of coverage under a group policy.
  • Co-pay: Under this arrangement, an insured pays a specified dollar amount for various services; the insurance company pays the rest.  This amount is normally payable by the insured at the time a service is rendered.
  • Deductible: The dollar amount which an insured agrees to pay, per claim or per accident, before the insurance company pays their portion.
  • Guaranteed coverage: A term from underwriting, describing the fact that a small business group cannot be turned down for health insurance because of poor health conditions, current or past.
  • High Risk Pool: This is health coverage for people who have been denied health insurance because of their serious medical conditions.  The plan designs vary from state to state.
  • Max Out-of-Pocket: The most, in dollars, that an insured will pay considering co-insurance, co-payments, deductibles, and so on.
  • Pre-existing conditions: When you apply for health insurance, the insurance company takes your medical history.  A ‘pre-existing condition‘ is an illness, physical or mental, that was treated (or should have been, in some cases) before getting health insurance.
  • Premium: The payment an insured makes to keep a policy in place.  With health coverage, usually monthly.
  • Providers: The doctors, clinics, hospitals and any other health professionals that provide care and services to an insured.
  • Qualifying Event: An occurrence – a death, termination of employment, divorce and so on – that changes an insured’s protection under COBRA, which requires continuation of benefits under a group insurance plan for former employees and their families who might otherwise lose health care coverage.
  • Stop Loss: A special type of re-insurance that protects an individual or group who goes over their coverage limit.
No matter how comfortable you get with these terms, however, nothing takes the place a good, professional insurance agent you trust to guide you through! 
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