Health Insurance and Life Insurance: Benefits Management Associates, Inc.: Serving Northwest Indiana

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Glossary

|| A || C || D || E || F || G || H || M || N || P || T || U

A
Actively At Work
Present and capable of carrying out the normal assigned job duties of the employer. Employees who are absent from work duet to health related disability, maternity leave or regularly scheduled vacation would be considered Actively at Work.

C
Coinsurance
The amount you are required to pay for medical care after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.

Co-pay
A flat fee every time you visit a doctor’s office, urgent care facility or hospital, purchase of prescription drugs, ECT. Depends on the policy.

Certificate of Coverage (COC)
The summary of the terms of your benefits.

D
Deductible
The amount of money you must pay each year to cover your medical care expenses before your insurance company starts paying.

Dependent
Any person of the Member’s immediate family who is eligible for coverage.

E
Explanation of Benefits (EOB)
A statement the insurance carrier sends you to explain how your claim was processed/paid.

F
Formulary
The list of pharmaceutical products, developed in consultation with physicians and pharmacist, approved for their quality and cost effectiveness.

G
Generic Drug
Drugs, which have been approved by the FDA to be bioequivalent to Brand Name Drugs and are not manufactured or marketed under a registered trade name or trademark. Generic Drugs must meet the same FDA specifications for safety, purity and potency and must be dispensed in the dame dosage form as the counterpart Brand Name Drug.

H
Health Maintenance Organization (HMO)
Prepaid health plans. You pay a monthly premium and the HMO covers your doctors’ visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use the doctors and hospitals designated by the HMO. You must have a referral from your Primary Care Physician.

M
Member
An employee or dependent that has satisfied the eligibility conditions, applies for coverage, been approved and enrolled by the insurance carrier and a premium payment has been made.

N
Network
A provider or facility that has entered into a contractual agreement to provide covered services under the Certificate of Coverage.

Name Brand Drug
A drug that is manufactured or marketed under a registered trade name or trademark.

P
Pre-existing Condition
A health problem that existed before the date your insurance became effective. If you have had prior coverage for 12 months without a break in coverage of less than 63 days pre-existing does not apply.

Preferred Provider Organization (PPO)
When you use the doctors and hospitals that are part of the PPO Network, you can have a larger part of your medical bills covered. You can us other doctors, but at a higher cost to you. You do not need a referral from a Primary Care Physician.

Provider
Any person (doctor, dentist, therapist, etc) or institution (hospital or clinic) that provides medical care.

T
Total Out of Pocket
The amount of money you are required to pay for medical care before the insurance carrier pays 100 percent of the claims.

U
Urgent Care Center
A health care facility that provides immediate, short-term medical care.