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Colorado Health and Life Insurance Terms

Colorado Health Insurance and Life Insurance can be confusing and unclear.  Colorado Health and Life Options is here to help with some simplified Insurance Definitions: 


Additional Insured:   Anyone covered under your health plan that is not named as the “insured.”

Benefit:   The dollar amount your insurance carrier will pay when you file a claim for a covered loss.

Benefit Period:   The interval during which you will be eligible for benefits.  Generally, your benefit period will begin with the first medical service you received for a specific illness and end after you have not been treated for that condition for 60 days or otherwise stated by your policy.

Carrier:   The insurance company that you have your health plan with and is also known as the policy holder.
Certificate of Insurance:   This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier.   It spells out precisely what will be covered, not covered, and the dollar maximums.
Claim:   Any request to your insurance company for benefits.
COBRA:   The Consolidated Omnibus Budget Reconciliation Act of 1985. The law requires group medical plans covering twenty employees or more to offer participants the option to receive continued healthcare benefits for up to eighteen months after the cancellation of their group plan.
Coinsurance:   The amount you will be required to pay for a particular medical expense.  Coinsurance is measured as a percentage of the total medical bill.
Co-payment:   A cost-sharing arrangement in which you will be responsible for a specific charge for a specific medical service ($20.00 per office visit, or $10.00 per generic prescription).
Covered Expenses:   The agreed coverage your insurer has agreed to provide you coverage for various medical procedures.
Deductible:   The amount you will be required to pay for healthcare expenses before your insurance plan will begin to reimburse you.
Exclusion:   A specific circumstance or condition that is not covered by your policy.
Effective Date:   The date your insurance coverage will actually begin.  
Fee-for-Service:  A payment system for healthcare where your provider is paid for each service after it is performed.  You receive reimbursement after a claim is filed.
Guarantee Issue:  Defined insurance plans where the applicant cannot be denied coverage based upon their medical condition.
Guaranteed Renewability:  A feature in health plans that means your coverage cannot be canceled because you get sick. HIPAA requires all health plans to be guaranteed renewable. Your coverage can be canceled for other reasons unrelated to your health status. 
HMO:  Health Maintenance Organization.  HMO’s are health benefit programs where payment premiums are made for managed coverage for your checkups, hospital stays, doctors' visits, surgery, emergency care, preventive care, lab tests, and X-rays.  A “Primary Care Physician” who will be responsible for coordinating your healthcare and making any referrals to specialists that you require.   Your services are all through doctors, hospitals and clinics which are members of your HMO plan's network. 
HSA:   Health Savings Account. An individual or family pays in contributions to Aetna and those contributions earn interest, which may be tax-deferred or tax-free. Withdrawals for medical expenses are tax-free withdrawals.
In-network:    Healthcare providers, specialists or providers who are members of your health care plan.
Lifetime Limit:  The maximum level on benefits available through a policy.
Length of Stay (LOS):  Used by insurance carriers, case managers, and other healthcare professionals to describe the length of time any individual spends in a hospital or an in-patient care facility.
Maximum Out-of-Pocket Expenses:  The total amount you will have to pay during one year in the total of deductibles and coinsurance fees.
Managed Care:   The broad assortment of health plans which manage healthcare costs and usage. The three major types of these plans and HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and POS (Point-Of-Service plans).
Medicaid:  A joint state/federal health insurance program that is administered by the state which provides health coverage for low-income individuals.  
Medicare:  A federally-sponsored healthcare program that offers coverage for medical and hospital care primarily to those over the age of 65.
Network:  The groups of doctors, hospitals and other medical professionals who have been contracted to provide discounted healthcare services to your insurance carrier’s customers.
Out-of-Network:   Any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO, POS, or PPO).  Depending on your plan’s guidelines, services provided by out-of-plan providers may not be covered, or partially covered.
POS:   Point-of-Service Plan. A POS is a managed healthcare plan that combines the features of a Health Maintenance Organization and a Preferred Provider Organization.  These plans allow you to decide whether or not you’ll use an in-network provider or an out-of-network provider.
Pre-existing Conditions:    Any healthcare issues prior to your insurance plan’s effective date.   Many policies will refuse to cover pre-existing conditions, while others do so only for a short time.
PPO:  Preferred Provider Organization.   PPOs are networks of healthcare providers who have negotiated discount contracts with health insurance carriers.  Although you may select your healthcare provider, there are generally financial incentives for you to select providers within your PPO network.
Preventative Care:  Health services that focus solely on preventative care measures such as physical exams, immunizations, diagnostic tests and mammograms.
Premium:   The dollar amount you’ll pay on a monthly basis in exchange for your insurance coverage.
Primary Care Physician:   Most HMOs and POS plans will require you to select one family physician, pediatrician or internist to monitor your health,  treat most of your health problems, and refer you to specialists when necessary.
Provider:    Any individual (nurse, physician, or specialist) or institution (clinic, hospital, or laboratory) that provides you with care.
Rider:   Any policy attachment that makes additions or changes to your original insurance plan.
Short Term Health Insurance:   A healthcare plan purchased to provide you with benefits during coverage gaps between jobs, after a move, or while you’re traveling overseas.
Small Business Health Insurance:   A type of healthcare coverage available to businesses employing between two and fifty employees. It offers discounted premiums to employees and tax advantages to small business owners; also in most cases, the coverage cannot be denied.
Travel Health Insurance:   Insurance is purchased to provide you with coverage when you’re traveling abroad.
Waiting Period:   Pre-specified time period during which you will not be covered by your insurance (for a particular healthcare issue).