Coinsurance - The amount you are required to pay for
medical
care in a fee-for-service plan after you have met your deductible. The
coinsurance rate is usually expressed as a percentage. For example if
the
insurance company pays 80 percent of the claim, you pay 20 percent.
Coordination of Benefits - A system to eliminate duplication
of benefits
when you are covered under more than one group plan. Benefits under the
two plans usually are limited to no more than 100 percent of the claim.
Co-payment - Another way of sharing medical costs.
You pay a
flat fee every time you receive a medical service (for example, $5 for
every visit to the doctor). The insurance company pays the rest.
Covered expenses - Most insurance plans, whether they are
fee-for- service,
HMOs, or PPOs, do not pay for all services. Some may not pay for
prescription
drugs. Others may not pay for mental health care. Covered services are
those medical procedures the insurer agrees to pay for. They are listed
in the policy.
Deductible - The amount of money you must pay each year to
cover your
medical care expenses before your insurance policy starts paying.
Exclusions - Specific conditions or circumstances for which
the policy
will not provide benefits.
HMO - (Health Maintenance Organization): Prepaid health
plans. You pay
a monthly premium and the HMO covers you doctors’ visits, hospital
stays,
emergency care, surgery, checkups, lab tests, x-rays, and therapy. You
must use the doctors and hospitals designated by the HMO.
Managed Care - Ways to manage costs, use, and quality of the
health
care system. All HMOs and PPOs, and many fee-for-service plans, have
managed
care.
Maximum Out-of-Pocket - The most money you will be required
to pay a
year for deductibles and coinsurance. It is a stated dollar amount set
by the insurance company, in addition to regular premiums.
Non-cancelable Policy - A policy that guarantees you can
receive insurance,
as long as you pay the premium. It is also called a guaranteed
renewable
policy.
PPO - (Preferred Provider Organization): A combination of
traditional
fee-for-service and an HMO. When you use the doctors and hospitals that
are part of the PPO, you can have a larger part of your medical bills
covered.
You can use the other doctors, but at a higher cost.
Pre-Authorization - Permission granted by the insurance
company for
certain services to be covered. This request is made by your doctor’s
office,
in most cases prior to services being rendered.
Pre-existing Condition - A health problem that existed
before the date
your insurance became effective.
Premium - The amount you or your employer pays in exchange
for insurance
coverage.
Primary Care Doctor - Usually your first contact for health
care. This
is often a family physician or internist, but some women use their
gynecologist.
A primary care doctor monitors your health and diagnosis and treats
minor
health problems, and refers you to specialists if another level of care
is needed.
Provider - Any person (doctor, nurse, dentist) or
institution (hospital
or clinic) that provides medical care.
Referral - A request for additional care, usually to see a
specialist,
made by your Primary Care Doctor.
Third-Party Payer - Any payer for health care services other
than you.
This can be an insurance company, an HMO, a PPO, or the Federal
Government.
Q: Why do I have more than one bill for some of my
services?
A: If you are seen at your doctor’s office, you will receive a bill
from MDI Health Centers for the visit. If you are seen in the hospital
or have lab work done at the doctor’s office, you will receive a bill
from
Mount Desert Island Hospital.
You may also receive a bill from an outside provider, such as
the radiologist who reads your CT scan or X-ray, or an outside
laboratory
that processes a specimen (such as Dahl Chase).
Q: Why do I have a co-payment?
A: Your insurance company and your individual policy determine your
co-payment amount. Because of the variation in insurance policies, any
questions regarding this amount should be directed to your insurance
company
directly.
Q: What is the difference between Medicare Part A
coverage and Medicare
Part B coverage?
A: Medicare Part A coverage covers inpatient hospital charges only.
Medicare Part B covers outpatient charges such as doctor’s office
charges,
laboratory, and radiology charges.
Q: Why do I receive so much correspondence after my
hospital/doctor’s
office visit?
A: In addition to the hospital bill, most insurance companies send
out an Explanation of Benefits. This letter explains which services
were
billed to the insurance company as well as what the insurance company
has
covered and what you are expected to pay for. This is done to help you
understand what your insurance company will cover and ensure that the
correct
services were billed to the insurance company.
