的术语表

在医疗保健系统中导航并非易事. 下面是一些重要的术语,有助于理解.

共同bwin手机APP

A percentage of a health care provider’s charge for which the patient is financially responsible under the terms of the policy.

是否值得

A flat-dollar amount that a patient must pay when visiting a health care provider.

可扣除的

A dollar amount that a patient must pay for health care services each year before the insurer will begin paying claims under a policy. ACA将小型团体保单的年度免赔额限制在2美元以内,个人bwin手机APP的bwin手机APP金额是10000, 和4美元,其他保单10000. 这些金额将每年调整,以反映保费的增长情况.

The Employee Retirement Income Security Act of 1974 (写) is a comprehensive and complex statute that federalizes the law of employee benefits. 写适用于大多数类型的员工福利计划, 包括医疗bwin手机APP, 哪些被称为员工福利福利计划.

外部覆核/上诉

An external review provides the consumer with the opportunity to have a person or entity with no connection to the health plan resolve the consumer’s dispute. The external review process decides whether the particular treatment is medically necessary and, 因此, 应该被健康计划覆盖吗. PPACA requires all health plans to provide an external review process that meets minimum standards.

祖父级的计划

个人在2010年3月23日前参加的健康计划. 祖父bwin手机APP计划不受ACA要求的大多数改变的限制. 新员工可能被添加到不受限制的团体计划中, 新的家庭成员可能会加入到所有祖父计划中.

团体健康计划

An employee welfare benefit plan that is established or maintained by an employer or by an employee organization (such as a union), 或两个, that provides medical care for participants or their dependents directly or through insurance, 报销或其他.

健康维护组织

A type of managed care organization (health plan) that provides health care coverage through a network of hospitals, 医生和其他卫生保健提供者. 通常, the HMO only pays for care that is provided from an in-network provider except for emergency services. 这取决于你的bwin手机APP种类, state and federal rules govern disputes between enrolled individuals and the plan.

网络服务提供商

A health care provider (such as a hospital or doctor) that is contracted to be part of the network for a managed care organization (such as an HMO or PPO). The provider agrees to the managed care organization’s rules and fee schedules in order to be part of the network and agrees not to balance bill patients for amounts beyond the agreed upon fee.

内部覆核/上诉

An internal review or appeal is the consumer’s first opportunity to challenge a health plan’s denial of payment, 治疗或服务. The consumer has a right to appeal after a denial, reduction, or termination of treatment. 除了, the consumer has a right to appeal after a failure by the health plan to pay for a benefit or after a health plan rescinds coverage except in cases of fraud or intentional misrepresentation. ACA requires all plans to conduct an internal review upon request of the patient or the patient’s representative.

既存状况排除

The period of time that a consumer does not receive health insurance coverage for health care services received due to a pre-existing medical condition. The ACA prohibits pre-existing exclusions for all plans beginning January 2014.

首选供应商组织(PPO)

A type of managed care organization (health plan) that provides health care coverage through a network of providers but also provides coverage for out-of-network providers. 通常 the PPO requires the policyholder to pay higher costs when they seek care from an out-of-network provider. 这取决于你的bwin手机APP种类, state and federal rules govern disputes between enrolled individuals and the plan.

预防带来的好处

Covered services that are intended to prevent disease or to identify disease while it is more easily treatable. The ACA requires insurers to provide coverage for preventive benefits without deductibles, 自付额或共同bwin手机APP.

溢价

维持保单所需要的定期付款.

废除

废除 occurs when a health plan retroactively terminates health care coverage. Health plans terminate coverage for individuals in this way when the health plan believes that there was a significant misrepresentation or an omission of important information by the consumer on the application for coverage. The health plan chooses to retro-actively terminate coverage in these situations because the health plan believes that it would never have offered coverage in the first place if not for the consumer’s false statements. ACA prohibits rescissions except in cases of fraud or intentional misrepresentation of a relevant fact.

自我bwin手机APP的

团体健康计划可以是自我bwin手机APP或完全bwin手机APP. A plan is self-insured (or self-funded) when the employer assumes the financial risk for providing health care benefits to its employees, i.e.,雇主自行支付申索费用. A plan is fully insured when all benefits are guaranteed under a contract of insurance that transfers that risk to an insurer.

Source: National Association of Insurance Commissions and The Center for Insurance Policy and Research

所提供的帮助

The bwin手机APP 热线服务电话 is a free multi-lingual statewide resource to help consumers with health coverage.

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bwin手机APP supports enrollment assisters working throughout the state.

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