The medical and dental fields are becoming evermore involved and complicated. With rising medical costs, and more red tape and paperwork it is making the participants become more proactive and hands on in making their medical coverage decisions. The SUP Welfare Plan is not immune to this. We are being subjected to rapidly escalating price increases from medical and dental carriers. In addition to this the carriers are requiring more work from our participants. The Welfare Plan receives phone calls and e-mails asking to describe certain medical and insurance terms. Listed below are some of the terms you may find, as well as the definitions of terms.
Allowable Charge: The maximum fee that a health plan will reimburse a provider for a given service.
Appeals: The process used by a member to request that the health plan reconsiders a previous authorization or denial decision.
Brand Name Drug: A prescription drug that has been patented and is only available through one manufacturer.
Claim: A request for payment for benefits received or services rendered.
Co-payment: A way in which the enrollee shares in the cost of health care. The benefit plan requires the enrollee to pay a flat dollar amount per unit of service. An example of a common co-pay is $10 per doctors visit.
COBRA: Consolidated Omnibus Budget Reconciliation Act: This is a federal law that requires most employers and plans to provide continuation of coverage for members as prescribed by current federal laws.
Deductible: An amount the insured person must pay for covered services during a calendar year, January 1 to December 31, before health benefit payments begin.
Explanation of Benefits (EOB): A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. The explanation usually includes the amount paid, the benefits available, reasons for denying payment, and the claims appeal process.
Generic Drug: A drug, which is the pharmaceutical equivalent to one or more brand name drugs. The Food and Drug Administration have approved such generic drugs as meeting the same standards of safety, purity, strength and effectiveness as the brand drug.
Health Maintenance Organization (HMO): A type of health care plan under which the enrollees receive all the medical services under a health benefit plan through a specific group of participating doctors and hospitals.
Non-Participating Provider: A medical provider who is not contracted with a health plan.
Participating Provider: A doctor, hospital pharmacy, laboratory, or appropriately licensed facility or provider of health care services that has entered into an agreement with a managed care entity, or HMO, to provide services to enrolled members.
Preferred Provider Organization (PPO): A type of health benefit plan designated to give enrollees incentives to use health care providers designated as “preferred providers”, but that also gives coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a Primary Care Physician. Although some HMOs may allow this.
Primary Care Physician: A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient’s regular physician and coordinates any other care the patient needs, such as seeing a specialist or hospitalization.