A Table of Technical Terms Used to Describe Plan Benefits
Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 16
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Table 7 - Technical Terms Used to Describe Plan Benefits
Technical Term |
Meaning |
| Co-Payment or Co-Insurance | The percentage of each medical bill that you must pay, once the deductible has been met |
| Yearly Individual Deductible | The amount that you need to pay each year before the insurer will generally begin to pay major medical claims |
| Preventive Care | Vaccinations, routine physical exams, and screening tests |
| Durable Medical Equipment | Equipment such as a power wheelchair or crutches |
| Family Coverage | Coverage for dependents |
| Family Deductible | Once several family members have met the yearly deductible, the deductible is assumed to have been met by all other family members |
| Yearly Co-Payment Maximum | The maximum amount you need to pay for covered major medical claims each year; once that amount has been reached, no co-payments are generally required, and claims for covered expenses are paid at the 100% rate |
| Yearly Benefit Maximum | That maximum amount of reimbursement that a policy will provide in terms of benefits during a calendar year |
| Lifetime Benefit Maximum | The maximum amount of reimbursement that a policy will provide in terms of benefits during a person's life time |
| Basic Benefits | Benefits for some X-rays and tests; in some cases, reimbursement may be provided even when the yearly deductible has not been met |
| Major Medical Benefits | Benefits for doctors' bills and for tests that are not covered under basic benefits |
| Usual and Customary Rate (the UCR) | The maximum amount of reimbursement an insurer will generally consider for a particular treatment or test |
| Percentile | The level of the array of charges at which reimbursement will be considered |
| Hospital Benefits (Inpatient), Hospital-Surgical Benefits | Benefits for an overnight stay in a hospital; includes coverage for nursing care, room, and food |
| Hospital Benefits (Outpatient) | Benefits for treatment in a hospital emergency room or a hospital same-day surgery facility, or for tests performed in a hospital on an outpatient basis; claims may be covered under major medical |
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