Final List of Terms Regarding Ohio Health Insurance

• Outpatient - A patient who receives care at a hospital or other health facility without being admitted to the facility. Outpatient care also refers to care given in other locations such as outpatient clinics.
• Policy Benefit Limits - Some plans limit the total amount the policy will pay over the course of your lifetime. Once your medical bills have reached the company's set limit, you can no longer use your policy. HMOs cannot have a lifetime dollar limit on covered basic health care services, although they may have annual limits on services which are not basic healthcare services.
• Pre-existing Condition (Pre-ex) - Health conditions or problems that were diagnosed or treated before health insurance was purchased. Check your policy for specific language defining pre-existing conditions.
• Pre-certification - A requirement that you obtain the insurance company's approval before a medical service is provided. If you fail to follow the pre-certification procedures the company may reduce or deny claim payment. Please note: getting pre-certification does not guarantee claim payment. Also called Utilization Review.
• Primary Payer - Health insurance policy that pays first when a person is covered by more than one insurance plan.
• Preferred Provider Organization (PPO) - An insurance company plan based on a network of providers. You may be able to see any doctor without a referral, although the plan will pay less if the doctor is outside its network. You normally have a copayment for office visits to a network doctor. Copayments may vary; deductibles, coinsurance and out-of-pocket maximums may also vary, depending on the plan.
• Provider - A person or organization that provides medical services, such as a doctor, hospital, x-ray company, home health agency, pharmacy, etc.
• Rider - A legal document that modifies an insurance policy. Riders may either extend or decrease benefits, or add or exclude specific conditions.
• Secondary Payer - Applies only when you have more than one health insurance plan. The secondary payer is the plan whose payments cannot be made until another plan (the primary payer) has processed the claim. Also see Coordination of Benefits.
• Self-insured Plan - An organization (usually an employer) that pays health care costs out of the organization's own pocket.
• Short-term health insurance - Health insurance that generally provides coverage for no longer than a year. Because you cannot carry eligibility from prior coverage to a short-term policy, a short-term health plan never covers pre-existing conditions. College alumni associations may offer this option to recent graduates.
• Speciic Disease Policy - A health insurance policy that covers the expenses incurred only for a specific disease named in the policy. Also known as Dread Disease policy. The most common type is cancer insurance.
• Underwriting - The process by which an insurer establishes and assumes risks. An insurance company is underwriting when it agrees to insure you because you are healthy or rejects your application because you have a history of health problems.
• Usual, Customary and Reasonable (UCR) - The dollar amount a company has determined to be the appropriate charge for a particular medical service. Each company sets its own UCR. It is often less than the billed charge.
• Waiting Period - The time you must wait before group health insurance from a new employer goes into effect.
• Waiver - An amendment to a health insurance policy that excludes coverage for a specific condition.