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ABOUT USTrustmark Medical Insurance GlossaryAllowable Charge – The maximum fee that a health plan will reimburse a provider for a given service. Annual Maximum – The maximum amount of benefits paid for specific covered charges on behalf of any covered person during a year. The Annual Maximums accumulate toward and are not in addition to the Lifetime Maximum. Benefit – Payments provided for covered services under the terms of the policy. The benefits may be paid to the covered person, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered, limits e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), subscriber incentives to use network providers. Benefit Period – The maximum length of time for which benefits will be paid. Claim – A request for payment for benefits received or services rendered. Coinsurance – The arrangement by which the cost of covered charges is shared by the covered person and Trustmark on a percentage basis. For example, a health plan might pay 80 percent of the allowable charge, with the covered person responsible for the remaining 20 percent; the 20 percent amount is then referred to as the coinsurance amount. Coordination of Benefits (COB) – The provision which applies when a covered person is covered by two health plans at the same time. The provision is designed so that the payments of both plans so not exceed 100 percent of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance I usually paid by the secondary plan to the limit of its responsibility. Benefits are thus “coordinated” between the two health plans. Copayment (or co-pay) – A way in which the covered person shares in the cost of health care. The benefit plan requires the covered person to pay a flat dollar amount per unit of service. An example of a common co-pay is $15 or $25 per physician office visit. Covered Charge(s) – That part of an expense incurred which:
If the hospital, physician or other provider waives the deductible or coinsurance, the entire charge is no longer a covered charge. Deductible – The amount a covered person must pay each year before benefits for covered charges will be paid. The deductible is shown on the schedule of benefits and is described in the application of deductible provision. Dependent – Person (spouse or child) other than the person who is covered in the subscriber’s benefit certificate. Also called a “member” or “beneficiary.” Effective Date – The date on which the coverage of an insurance policy goes into effect at 12:01 a.m. Exclusions – Specific conditions or circumstances that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand which services are not covered benefits. Explanation of Benefits (EOB) – A form sent to the covered person after a claim for payment has been processed by the health plan. The form explains the action taken on the claim. This explanation usually indicates the amount paid, the benefits available, reasons for denying payment, or the claims appeal process. Encounter Fee – A charge for each visit to a physician’s office. The encounter fee is described in the application of encounter fee provision. Lifetime Maximum – The maximum amount of benefits that will be paid for covered charges on behalf of any covered person over the time that person is insured by Trustmark.. Benefits paid under more than one policy or certificate issued through the employer may be added together to determine when a covered person has reached the Lifetime Maximum. The Lifetime Maximum is subject to the provision titled termination of coverage and reinstatement of maximum. The Lifetime Maximum is shown on the Schedule of Benefits. Out-of-Pocket Maximum – The total amount a covered person must pay before his benefits ate paid at 100 percent. It does not include charges applied to the deductible. The Out-of-Pocket Maximum is reached by a covered person’s payment of his share of the In-Network or Out-of-Network Coinsurance percentage, as described in the application of Out-of-Pocket Maximum provision. The Out-of-Pocket Maximum is shown on the Schedule of Benefits. Pre-Existing Condition – A sickness or injury for which a person has, during the six months just prior to his effective date:
Pregnancy is not considered a Pre-Existing Condition. Such condition will be deemed to be pre-existing if any of the above has occurred whether or not a final diagnosis has been made prior to the effective date of the person’s coverage. Precertification – A utilization management program that requires the covered person or the health care provider to notify the insurer prior to a hospitalization or surgical procedure. The notification allows the insured to authorize payment, as well as to recommend alternate courses of action. Reasonable and Customary (R&C) – The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Schedule of Benefits – A list of maximum amounts payable for certain conditions. Source: America's Health Insurance Plans; www.ahip.org |
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© 2012 Trustmark Companies (Trustmark Mutual Holding Company) and its subsidiaries |
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