Ralston
long-term travel disability health medicare
(p) 208.433.0344 (f) 208.433.1076

Glossary

A

Ancillary Services - Services, other than those provided by your physician or hospital, that are related to your care, like lab work, x-rays and anesthesia.

C

Calendar Year - The period beginning January 1 of any year through December 31 of the same year.

Case Management - A process we develop to help you if you have specific health care needs. A company representative works with you to make sure health care resources are used to get you the best outcome in the most efficient and cost-effective way.

Certificate of Coverage - A document given to you that describes the benefits, limitations and exclusions of coverage provided by us.

Claim - Information a doctor, hospital or you submit to us to request payment for medical services provided.

Coinsurance - Coinsurance is the percentage of covered expense you are responsible for after you meet your deductible. For example, you can choose 20% coinsurance of $5,000 (which equals $1,000). That means you'll pay 20% and we pay 80% of the first $5,000 (which equals $4,000) of covered expenses. After that, we pay 100% of covered charges for the remainder of the year, up to the policy maximum.

Coordination of Benefits (COB) - A provision in the health insurance contract that applies when you are covered under more than one medical plan. It requires that payment of benefits be coordinated by all plans to eliminate the duplication of payment.

Copayment - The set amount that you pay for a specific service, such as $25 for an office visit. You are usually responsible for payment at the time of service.

Covered Person - An individual who meets eligibility requirements and for whom premium payments are paid for specific benefits in the health insurance contract.

D

Deductible - The amount you pay each calendar year before insurance benefits are provided for covered medical expenses.

Dependent - A covered person who relies on another person for support or obtains health coverage through a spouse, parent or grandparent who is the covered person under a plan.

E

Effective Date - The date your insurance coverage begins.

Eligible Dependent - A dependent of a covered person (spouse, child, or other dependent) who meets all requirements specified in the contract to qualify for coverage and for whom premium payment is made.

Eligible Expenses - Either the reasonable and customary charges or the agreed-upon fee for health services and supplies covered under a health plan. Note: See "reasonable and customary" for definition.

Explanation of Benefits (EOB) - The statement sent to you by us that lists services provided, amount billed, eligible expenses and payment made by us.

I

Insured - A person who has obtained health insurance coverage under a health insurance plan.

L

Lifetime Maximum - The maximum amount a plan will pay while you are insured.

O

Out-of-Pocket Maximum - The total payments that must be paid by you (like your deductible and coinsurance) as defined by your contract. Once this limit is reached, covered health services are paid at 100% for health services received during the rest of that calendar year.

P

Participating Provider - A doctor, hospital or other medical facility that's made an arrangement with us to provide medical services or supplies to you at a pre-negotiated fee.

Preferred Provider Organization (PPO) - An arrangement that offers you access to participating providers at reduced costs. Insurers provide you with incentives, such as lower deductibles and copayments, to use providers in the network. Network providers agree to negotiated fees in exchange for their preferred provider status.

Provider - A physician, hospital, health professional and other entity or institutional health care provider that provides a health care service.

R

Reasonable and Customary (R &C) - A term used to refer to the amount that's commonly charged for a particular service within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for a particular service within a specific community.

U

Underwriting - The process an insurance company uses to review and evaluate a potential customer for risk assessment and appropriate premium

Ralston