Health Insurance Terms and Definitions Pt3

Health Insurance Terms and Definitions Pt3

Explanation of benefits

This is the form which the health insurance firm sends to you after completing the processing of your Medical Insurance Plans for Individuals 2020 claim that you got.  It details the invoice received and how it was processed. It is commonly called EOB.

Coordination of Benefits

If you qualify to receive benefits under more than one health insurance plan, your various health insurance companies must coordinate the benefits. This ensures that nothing above 100% of the total fee is paid. There are a variety of ways on how this condition can occur. Generally speaking, the main company makes its payment first. Then send a copy of the charges to the secondary company along with a copy of the company’s Explanation of Benefits (EOB). The secondary company usually pays for the remainder of the invoice.

Participating Provider

A participating provider is a medical provider who has signed a contract with a health insurance firm or a health insurance network to charge pre-determined fees to patients on the network.

Non-participating provider

A non-participating provider is a provider of medical services who does not have a contract with a particular healthcare network or company. If you use a non-participating provider, you will generally pay a larger share of the account. In some cases, you may be responsible for the entire payment.

Limited benefit plans

These are not considered comprehensive health insurance plans. Rather, they offer very limited and specific benefits for diverse types of services offered. For instance, they could offer a flat rate for every day of hospital stay or pay a limited amount for each surgical procedure you have. They are usually marketed to people who cannot afford it or cannot get more complete coverage due to pre-existing health conditions. Or, they can be geared towards people who have plans with high deductibles. The good thing about these plans is that they generally pay in addition to any other coverage they may have. Therefore, co-ordination of benefits is not necessary. If this is your only coverage, keep in mind that you will usually have to pay a large portion of the bill, since these limited plans do not pay large amounts each day. For example, it can actually cost you $1,000 a day to stay in the hospital. If your limited benefit plan pays you $200 per day for each day you spend in the hospital, you will be personally responsible for the remaining $800 per day.

Medicare Supplement Plans

People with Medicare often choose to purchase a Medicare supplement plan, since Medicare generally does not cover medical expenses in full. Medicare continues to change and add new options, but in general, a supplemental plan pays the balance of medical expenses after Medicare pays its share. For example, many supplements of Medicare will offer the deductible of Medicare. Certain plans also pay for some of the bills that Medicare does not cover. There are many different political variations. If you are not sure what you are buying, consider contacting a broker who helps seniors.