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The overall idea of health insurance is easy to comprehend but behind is a complex product that you should understand in order to get the best product for you.

Health Insurance Terminology

Benefit: Health insurance benefits are financial terms and parameters of the services that are covered under your health insurance policy.

COBRA: The Consolidated Omnibus Budget Reconciliation Act (COBRA) ensures group health insurance participants that they can continue receiving coverage under a group policy for a limited period of time after leaving the group. The COBRA act also protects dependents in the event that the group member dies or divorces them. This is exclusively helpful to individuals who are uninsurable or highly rated as a result of pre-existing conditions.

Coinsurance: Coinsurance is a percentage that the insured pays after the deductible has been met and does not generally exceed 20% of the cost of the procedure, treatment or visit.

Copayment: After your deductible has been reached, or in an insurance policy with no deductible, there is a flat fee that you must pay for the services you receive each time you receive them. This is called copayment.

Deductible: The deductible is the amount of money you must pay before your insurance company will begin paying any benefit.

Exclusions: The exclusions are any medical condition, illness or injury whose medical expenses are not included for coverage under the plan and that sometimes are referred to as riders.

Explanation of Benefits (EOB): Your insurance company will send you an accounting of all the procedures you had, the cost of the procedures and the amount the insurer paid for them under your policy. This is called EOB.

Health Insurance Portability and Accountability Act (HIPAA): The HIPAA governs the electronic privacy standards of health insurers and guarantees insurability after COBRA coverage ends as long as there has been continuous creditable coverage without a break of 63 days or longer (this number can vary depending on your state of residence).

Health Maintenance Organization (HMO): Health insurance ‘works’ because there is a network of medical facilities and doctors willing to perform services at the predetermined insurance company’s rate and to bill the insurance company for payment. When you have an HMO plan, you have a restricted network that you can visit for treatment. If you visit anyone outside that network there will be no insurance benefit paid against your claim and any out-of-pocket expenses will not be considered as part of your deductible.

Pre-existing conditions: If you were diagnosed with a chronic illness or injury before you became insured, this is considered a pre-existing condition. In group insurance, pre-existing conditions can be excluded in most states if you had a 63-day or longer gap in creditable coverage. Individual policies can exclude pre-existing conditions in most states whether or not there has been a gap in coverage. Some pre-existing conditions can even render the consumer uninsurable.

Preferred Provider Organization (PPO): A PPO is similar to an HMO, but they offer a minimal benefit if you decide to visit a healthcare provider or facility outside the network of medical facilities and doctors.

To learn more about Health Insurance contact us today (813) 933-6691 or get a quote.

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