Plan types Insurance Terms General Knowledge
100
What is PPO?
A health plan that supplies services at a higher level of benefits when members use contracted health care providers. provide coverage for services rendered by health care providers who are not part of the network; however, the plan member generally shares a greater portion of the cost for such services.
100
What is an EOB (explanation of benefits)?
created after a claim payment has been processed by your health plan. It explains the actions taken on a claim, such as the amount that will be paid, the benefit available, discounts, reasons for denying payment and the claims appeal process, available as a paper copy or electronically. 
100
What is a claim?
An itemized bill from a health care provider, for health services provided to a member
200
What is a group plan?
A group of people covered under the same health plan and identified by their relation to the same employer or organization
200
What is an exclusion?
Specific medical condition or circumstance that is not covered under a health plan
200
What is Out Of Network?
when you use a doctor or other provider that does not have a contract with your health plan services may not be covered or may be covered at a lower level. You may be responsible for all or part of bill.
300
What is HIPAA?
A federal law that outlines the rules and requirements plans must follow to provide health care insurance coverage for individuals and groups
300
What is deductible?
The amount you pay for most covered services before your health plan starts to pay, resets at the beginning of the calendar year or when you enroll in a new plan.
300
What is Out of pocket Maximum?
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copays and coinsurance, your health plan pays 100 percent of the costs of covered benefits.
400
What is HMO?
A type of health plan that provides health care coverage to its members through a network of doctors, hospitals and other health care providers. may cost less than other plans but has some limitations.
400
What is copay?
The set dollar amount you pay for a covered health care service at the time you get care or when you pick up a prescription drug
400
What is Open enrollment period?
The period of time set up to allow you to enroll in a health plan, usually once a year
500
What is EPO?
PPO type plan, no referrals required, Limited OUT OF NETWORK coverage
500
What is Coinsurance?
The percentage of the costs of a covered health care service or prescription drug you pay after you've paid your deductible. You pay 100 percent of the full allowed amount until you meet your deductible
500
What is In Network?
Services provided by a physician or other health care provider with a contractual agreement with the insurance company and covered at a higher benefit level




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