You may be wondering about some of the terms used in health insurance. Here are some common terms and definitions.
Allowable charges: The insurance company's allowance for a specific medical expense or the provider's charge for a particular service, whichever is less.
Brand-name prescription drug: A drug that is manufactured and marketed under a trademark or name by a specific manufacturer or that the insurance company identifies as a brand-name product. Typically, the copayment is higher for these medications than generic prescription drugs.
Claim: A request for payment under the terms of an insurance policy.
Claim examiner: An insurance company employee who is responsible for carrying out the process of determining what benefits, if any, are payable by them for the medical expenses.
Coinsurance: A specified percentage of the cost of covered medical expenses the student is required directly to the provider after the policy deductible has been met.
Comprehensive major medical policy: A health insurance plan that covers both major medical coverage (i.e. hospitalization and surgeries) and basic medical expense coverage (i.e. doctor's visits and diagnostic labs).
Coordination of benefits provision: A health insurance policy provision that sets forth some guidelines to determine which insurance company will pay as the primary insurer and which will pay as the secondary insurer when the insured individual has more than one health insurance policy.
Copay: A fixed dollar amount you pay at the time services are rendered. Typically copays are for office and emergency room visits.
Covered medical expenses: Any charges incurred by the student for services and supplies that are included in the schedule of benefits and not excluded under the policy and that are medically necessary and are not in excess of the usual and customary charges.
Deductible: The portion of your healthcare costs that the student pays before the insurance company starts covering it. For the W&M plan, there is a policy deductible of $200 per person per policy year and an additional inpatient deductible of $250 per person per policy year.
Excess provision: A health insurance policy provision that states that if the insured student has any other valid and collectible group insurance, the student insurance plan will pay benefits on the unpaid balances after your primary insurance carrier has paid.
Effective date: The date upon which the insured student's insurance coverage begins.
Emergency room visit: A visit to the emergency department of a hospital for the treatment of an accidental injury or sudden, severe sickness. To qualify as a medical emergency, the symptoms must be sudden, serious and unexpected and require immediate medical attention.
Exclusions and limitations: Conditions, situations and services that are not covered by the health plan.
Generic prescription drug: A drug that is chemically equivalent to the brand-name drug or that the insurance company identifies as generic. Typically the copay is less for these medications than brand-name drugs.
Healthcare provider: A doctor, physician's assistant, nurse, hospital, laboratory, facility or anyone else who delivers medical or health-related care.
Lifetime maximum: The maximum amount of money a plan will pay for healthcare services over the course of the student's lifetime.
Medically necessary: A service or supply provided or prescribed, in accordance with the standards of good medical practice, by a hospital or physician for the diagnosis and treatment of an injury or sickness or is essential for the symptoms of an injury or sickness and is not primarily for the convenience of the student or his/her physician.
Network: A group of doctors, hospitals and other healthcare providers contracting with a health plan to provide care at a special rate and to handle paperwork with the health plan.
Network area: means the designated radius around the local school campus the student is attending. The W&M network area is defined as a 10 mile radius.
Office visit: Any time you visit a physician at his/her office for medical care. You may only be examined and not necessarily treated by the doctor to be charged for an office visit.
Out-of-network: Healthcare services or providers who are outside the Preferred Provider network. The Preferred Provider for the W&M Plan is UnitedHealthcare Options PPO.
Out-of-pocket expense: Any healthcare costs not covered by insurance that must be paid by the insured student.
Policy: A written document that contains the terms of the contractual agreement between the insurance company and the owner of the policy. W&M is the policyowner of the College-endorsed student insurance plan.
Policy year: The period of time that the policy is to remain in force. The W&M policy is a one-year term policy.
Preferred allowance: The amount a Preferred Provider will accept as payment in full for covered medical expenses.
Preferred Provider Organization (PPO): An organization where providers are under contract to an insurance company or health plan to provide care at a negotiated or discounted rate. Most PPOs will also allow students to see care outside of the PPO network, however benefits are usually reduced and the student has a greater out-of-pocket expense.
Prescription Drug: A medication, product or device that has been approved by the U. S. Food and Drug Administration and that under federal and state law can only be dispensed with a prescription order or refill.
Prescription Drug List (PDL): A list in which the insurance company has categorized into tiers prescription drugs. Typically, the PDL is subject to periodic review and modification by the insurance company. To determine to which tier a particular prescription drug has been assigned, students should call the telephone number listed on their ID card.
Pre-existing condition: Any illness, disease or condition an individual has at the time of enrollment into the student insurance plan. Pre-existing conditions may be covered after a designated waiting period.
Premium: The semesterly or annual cost students pay for their health insurance.
Primary insurance carrier: The insurance company that pays first when an individual has more than one health insurance policy.
Schedule of benefits: The listing of the types of healthcare costs that will be covered by the insurance plan and any applicable coinsurance, copayments, deductibles, and benefit maximums. Typically this information is presented in a table format.
Secondary (or excess) insurance carrier: The insurance company that pays second or after the primary insurance carrier has paid when an individual has more than one health insurance policy.
Termination date: The date upon which the insured student's insurance coverage ends.
Usual and customary charges: A reasonable charge for a specific healthcare product or service as calculated by an outside agency when compared with the charges for similar services or supplies in the geographic area where the plan operates. The W&M plan does not pay for any expenses in excess of the usual and customary charges.