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UNIVERSITY of ARKANSAS PAT WALKER HEALTH CENTER |
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Student Health Insurance |
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Student Health Insurance General Information
Info for Graduate and Teaching Assistants
Health Insurance Education Initiative
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Glossary of Insurance Terms (The terms are listed in alphabetical order and serve to assist with understanding typically common language used within the insurance industry.) Agent – Advisor(s) who work on behalf of the insurance company to assess your insurance needs and protect your financial future. Balance Billing: A bill for the difference between what your insurer will pay and what the physician charges for a service. Benefit
– potential items you can receive payment
for under your insurance policy. Example: an eye care benefit of $50 would
pay $50 for eye care. Cancellable - A contract of insurance that may be terminated by the insurance company or the insured at any time. Catastrophic Insurance – policies that have a high deductible; may not cover ordinary doctor office visits. Usually do not have any maximum on benefits covered once deductible met. Claim - The demand for benefits as provided in the policy. 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. Comprehensive Insurance – policies that combine major medical and basic hospital insurance. 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 are usually limited to no more than 100 percent of the claim. Co-Payment
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Amount of money you, as a patient, would be expected to pay for a service.
For example, doctor office co-pay of $15. At each doctor visit, one would
be expected to pay $15. Coverage - The scope of protection provided under a contract of insurance. Covered
Expenses
– Most insurance plan will only pay for certain services. Covered
expenses are those medical services that your insurance policy agrees to
pay for. COBRA
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A federal law that allows an employee in a group health insurance plan to
extend their insurance after leaving the job (unless fired) for up to 18
months. Often this costs more than they paid while employed. Declination- Rejection of an application for insurance by an insurer. Deductible – An amount of money you must pay out of pocket before the insurance company will begin payment. Dependent- Spouse of the Named Insured and their dependent unmarried children. Dismemberment - Loss of, or loss of use of, specified members of the body (parts) from accidental bodily injury. Effective Date - The date on which an insurance policy or bond goes into effect Elective Surgery- (or treatment) - those health care services or supplies that do not meet the health care need for a sickness or injury. Elective surgery or treatment includes any service, treatment, or supplies that 1)are deemed by your insurance company to be research or experimental 2)are not recognized or generally accepted medical practices in the United States Enrollment - Period of time in which you are able to join a group insurance policy. Exclusions – Specific Conditions or circumstances for which a policy will provide no benefits. Group Insurance - Insurance provided through an employer and offered to all employees. Health Maintenance Organization HMO – An insurance that attempts to reduce medical expenses by emphasizing preventative care. Often very strict on Out of Service area care. Hospital - a licensed or properly accredited general hospital which 1)is open at all times 2) is operated primarily and continuously for the treatment and surgery of the sick or injured 3)is supervised by a staff of one or more legally qualified Physicians at all times 4) continuously provides on the premises 24 hour nursing services by RNs 5)organized facilities for diagnosis and major survey on premises 6) is not primarily a clinic, nursing, rest or convalescent home Hospital Confined/Hospital Confinement- Confined in a hospital for at least 18 hours by reason of an injury or sickness for which benefits are payable Injury - bodily harm which is 1)directly and independently caused by specific accidental contact with another body or object 2) unrelated to any pathological, functional, or structural disorder 3) a source of loss 4) treated by a Physician within 30 days of the causing accident 5) sustained while the insured person is covered under the policy. All injuries sustained in one accident, included related conditions and recurrent symptoms, are considered one injury. Insured Person - means 1)the named insured and 2)any dependents of the Name insured included in the policy Intensive Care- Means a specifically designated faculty of the hospital that provides the highest level of medical care- usually restricted to those patients who are critically ill or injured Limit of Liability- The maximum amount which an insurance company agrees to pay in case of loss. Limitations- Exclusions, exceptions, or reductions of coverage contained in the health policy. Major
Medical Insurance- An
insurance that has higher medical benefits higher deductibles. Managed Care: The way a health care system manages costs, use, and quality. All HMOs and PPOs, and even many fee-for-service plans, apply managed care techniques. Maximum Out-of-pocket – The maximum amount of money you will be required to pay in one year including all deductibles and co-insurance. Medical Emergency - occurrence of a sudden, serious and unexpected Sickness or injury. In absence of immediate medical care should/would result in death, placement of body in jeopardy, serious impairment of bodily functions, serious dysfunction of any body or organ part, and/or, in the event of a pregnant woman, serious jeopardy to the health of the fetus. Medical Necessity - Means those services or supplies that are provided or prescribed by a Hospital or Physician which are essential for the symptoms, diagnosis, or treatment of the sickness or injury and are in accordance with standards of medical practice. Mental Disorder- or nervous disorder - Sickness that is emotional, mental, or behavioral in nature. If not excluded or defined in policy, all diagnoses classified as "Mental Disorder" according to the International Classification of Diseases are considered Sickness. Miscellaneous Expenses- Usually hospital charges other than board and room (x-rays, drugs, lab, etc.) Named Insured- means the eligible, registered policy holder of insurance Noncancellable Policy: A policy that guarantees that you will receive insurance as long as you pay the premium. This is also known as a guaranteed renewable policy. Pre-existing Condition – A condition that was encountered by the patient before that insurance coverage starts. See more information here. Preferred
Provider Organization PPO-
an insurance that is made up of various hospitals and doctors that agree
to provide services to clients of a particular insurance for a
predetermined price. If you see a non-preferred provider, often benefits
are reduced by a certain percentage. (you pay more co-pay). Premium
– the money paid to have insurance. Primary Care Physician – A primary care physician monitors your health, diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed. (a.k.a. Primary Care Provider). Sickness - an disease or illness of the insured person which causes loss Usual and Customary Charges - A reasonable charge which is: 1)average compared with charges made for similar services and supplies and 2) made to persons having similar medical condition in the same local area
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