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Health Insurance Glossary of Terms - Part 2

Exclusion

If you have been diagnosed or treated for a previous condition, illness, or injury, before you were insured, the health insurance carrier may not want to cover continuing treatment for that medical condition. The carrier does not want people to wait to purchase insurance coverage until they know they will need treatment. When a condition is already known to the consumer, the carrier may offer health insurance that covers other conditions that arise, but excludes treatment for anything that was pre-existing before the insurance was purchased. Naming specific illnesses, injuries or conditions that are "exclusions" on the policy means that the carrier will not pay for any treatment associated with them. Some individual health policies may allow coverage for the pre-existing condition after a certain time period (usually 12 months) has passed with continuous health insurance coverage.

An exclusion in your policy may also mean refer to anything the health insurance carrier will not cover, ranging from a type of drug to alternative treatments to a type of surgery. These exclusions can vary from policy to policy. A hospital stay may list a number of exclusions, sometimes anything "extra" that is not a medical necessity - from watching a rental television to using a hospital phone to deluxe meals - may not be covered. Cosmetic or elective surgery is often excluded, unless it is done in response to a medical condition. Dental treatment and vision needs are usually excluded unless treatment is required due to an accident or illness. If dental and or vision treatments are covered, it should be spelled out in your policy.

An exclusionary rider is a part of your policy that states when there are certain conditions or types of illnesses that will NOT be covered by your policy. The exclusionary rider eliminates coverage for any medical treatment associated with the medical condition or previously diagnosed illness specified on the rider.

Health Savings Account (HSA)

A Health Savings Account is a type of savings product that offers a different way for consumers to pay for their health care. HSAs are designed to encourage individuals to save money they may need for future health care expenses on a tax-free basis.

To be able to take advantage of HSAs, you must be covered by a qualified High Deductible Health Plan (HDHP). Because an HDHP generally costs less than what traditional health care coverage costs, the money saved on insurance can be put into the Health Savings Account.

People can sign up for Health Savings Accounts with banks, credit unions, and insurance companies, and sometimes their employers. The IRS has more information on the tax benefits and consequences of HSAs.

Limited Benefit Health Insurance Policies

"Limited benefit health insurance policies" can cost far less than traditional insurance, but cap what health insurance carriers will pay toward medical care. For example, the policy may pay $2,500 per person, per year, an amount that would be exhausted by a single trip to the emergency room. Some limited benefit health insurance policies have daily caps, such as paying a few hundred dollars a day toward hospital coverage. This differs from traditional health insurance, which generally covers most medical expenses in a given year, after deductibles and co-payments have been made.

Before purchasing a "limited benefit health insurance policy", find out if you will be covered for hospital visits or routine doctor's care and make sure you understand the all of the limits in the benefits provided.

Major Medical Health Insurance

Major Medical health insurance policies typically provide comprehensive coverage for hospital, doctor, x-ray and laboratory expenses.

Mandated Health Benefit

Mandated health benefits are benefits that are required to be covered by law. There are both federal and state mandated benefits. In Colorado (as in many states), the mandated health benefits may not apply to all types of health insurance policies or plans offered in the state. Some mandated health benefits are required of group health plans, but not of individual policies. If you have previously been covered by a group health plan, and are now shopping for individual health insurance, check carefully to see what the new policy covers. Many people assume that individual policies will have the same health mandates, and they may not. Covering some of these health mandates is optional for individual health policies.

There are some mandated benefits that are required by federal law, and there are some that are required by state law. Colorado statutes may mandate some benefits for certain types of insurance (benefits that must be covered by group plans, for example), that are not mandated for all types of insurance (such as individual coverage.)

Pre-existing Condition

If you have experienced an illness or disability for which you have been diagnosed, treated or advised, that is considered a "pre-existing condition." When you apply for an individual health insurance policy, you will be asked to describe any pre-existing conditions or previous treatment. The health insurance carrier may decide to offer you health coverage with an "exclusion" for the specific condition, even if you are not currently experiencing problems. This means the carrier will not cover any medical treatment for the excluded condition. Failing to mention a pre-existing condition for which you have previously sought medical advice is a reason for the carrier to rescind or cancel your policy at a later date. It is always advisable to provide a full and complete medical history.

Premium

The amount paid to the health insurance carrier each month to purchase health coverage. The premium is paid by the policyholder on an individual policy. On employer group plans, the cost of the premium amount can be shared by the employee and the employer.

Reasonable and Customary Charges (also called "Usual, Customary and Reasonable" or UCR)

The cost associated with a health care service that is consistent with the going rate for identical or similar services within a particular geographic area. Reimbursement for out-of-network providers is often set at a percentage of the "usual, customary and reasonable" charge, which may differ from what the provider actually charges for a service. When an insurer disallows a portion of a charge as being in excess of the Usual and Customary allowance, it means only that the charge is in excess of the standard the company used to determine Usual and Customary, or UCR. Providers are free to charge whatever fee for service they choose. Your insurance coverage is designed to provide benefits up to the plan's Usual and Customary percentile and is priced accordingly. Your policy should contain a definition of Reasonable and Customary (or UCR) and explain how claims will be paid. If you disagree with the amount paid or if you believe a claim was denied improperly, there is a step-by-step process by which consumers may appeal the decision.