Health Insurance Terms and Definitions

One of the biggest problems for most people is simply understanding the health insurance benefits that they have. For the most part, health insurance policies try to be user-friendly in their wording, but many people are just not familiar with medical and insurance terminology.Most health insurance policies also provide something similar to a cheat sheet which gives the basic outline of policy coverage and covers the most common medical services. However, you need to be sure that you understand the different things that are excluded under your plan. Many health insurance plans provide limited benefits for services such as mental health, chiropractic services, and occupational health. Even physical therapy and home health care are often limited to a certain number of visits per year.Co-payment or Co-payA co-payment is a pre-determined amount that you must pay a medical provider for a particular type of service. For example, you may be required to pay a $15 co-payment when you visit your doctor. In this instance, you must pay $15 to the doctor’s office at the time of the visit. Normally, you are not required to pay any additional fees — your health insurance company will pay the rest. However, in some cases, if your health insurance policy specifies it, you may be responsible for a co-payment and then a percentage of the remaining balance.DeductibleA deductible is the amount of your medical expenses you must pay for before the health insurance company will begin to pay benefits. Most health insurance plans have a calendar-year deductible which means that in January of every new year the deductible requirement starts over again. So, if your calendar year deductible is $1500, as long as your medical expenses for the current year do not exceed $1500 the insurance company pays nothing for that year. Once January of the new year starts, you have to begin again to pay for $1500 of your own medical expenses.CoinsuranceCoinsurance (or out-of-pocket expense) is the amount or percentage of each medical charge that you are required to pay. For example, you may have a $100 medical charge. Your health insurance company will pay 80% of the charge and you are responsible for the additional 20%. The 20% is your coinsurance amount.Coinsurance accrues throughout the year. If you have a large number of medical charges in one year, you may meet the coinsurance maximum requirement for your policy. At that point, any covered charges will be paid at 100% for the remainder of the calendar year.Stop loss or out-of-pocket expense limitSometimes you will hear the out-of-pocket expense limit referred to as your stop loss or coinsurance amount. Basically, this is the amount you will need to pay out of your own pocket per calendar year before the health insurance company pays everything at 100%.You will need to check your policy because many policies that require co-payments do not allow these co-payments to go toward the out-of-pocket amount. For example, you may have reached your out-of-pocket maximum for the year, so if you are admitted to the hospital you may pay nothing. However, since you have to pay a $15 co-payment every time you visit the doctor, you will still have to make this co-payment.Lifetime maximum benefitThis is the maximum amount that the health insurance company will pay toward your medical expenses for the lifetime of your policy. Generally, this amount is in the millions of dollars. Unless you have a very severe condition, you will not likely exhaust this amount.Preferred Provider OrganizationA Preferred Provider Organization (also known as a PPO) is a group of participating medical providers who have agreed to work with the health insurance company at a discounted rate. It’s a win-win situation for each side. The insurance company has to pay less money and the providers receive automatic referrals.In most health insurance policies, you will see different benefit levels depending on whether you visit a participating or nonparticipating provider. A PPO plan provides more flexibility for the insured person because they can visit either a participating or nonparticipating provider. They just receive a better price if they use a participating one.Health Maintenance OrganizationA Health Maintenance Organization (also known as an HMO) is a health insurance plan which restricts you to only using specified medical providers. Generally, unless you are out of the area of their network, no benefits are payable if you go to a nonparticipating physician. Typically, you are required to select one main doctor who will be your Primary Care Physician (PCP). Any time you have a health problem, you must visit this doctor first. If they feel that you need it, they will refer you to another network provider. However, you cannot just decide on your own to visit a specialist; you must go through your PCP.Medically necessaryYou will see this term in all health insurance policies, and it is a frequent cause of denied claims. Most insurance companies will not cover any expenses that they do not consider medically necessary. Just because you and/or your doctor consider something medically necessary, your health insurance company may not. For this reason, you always need to verify that any costly procedures you are considering will be covered.Routine treatmentRoutine treatment is generally defined as preventive services. For example, a yearly physical examination that you have on a regular basis is generally considered to be routine. Many of the immunizations that children and adults receive fall under this classification. Some insurance companies provide limited coverage for routine treatment; others provide no benefits at all.Pre-existing conditionA pre-existing condition is a condition that you acquired and/or received treatment for prior to the effective date of your current health insurance policy. Health insurance companies vary on how they treat pre-existing conditions. Some companies will not give you coverage at all if you have certain chronic pre-existing conditions. Others will give you coverage but will not provide any benefits for a period of time — usually from 12-24 months. Still, other health insurance companies will specifically exclude a pre-existing condition from a policy and will never provide any benefits for that condition.Be sure that you are very clear on the pre-existing limitations of your policy so that you are not unpleasantly surprised when you visit your doctor.Explanation of BenefitsThis is the form that the health insurance company sends you after they complete the handling of your claim. It details the bill they received and how they processed it. It is commonly called an EOB.Coordination of BenefitsIf you are eligible for benefits under more than one health insurance plan, your various health insurance companies will need to coordinate benefits. This insures that no more than 100% of the total charge is paid. There are many variations on how this situation can occur. In general, the primary company makes their payment first. Then you file a copy of the charges with the secondary company along with a copy of the Explanation of Benefits (EOB) from the primary company. The secondary company usually picks up the remainder of the bill.Participating providerA participating provider is a medical provider who has signed a contract with a health insurance company or health insurance network to charge pre-determined rates to patients who are in the network.Nonparticipating providerA nonparticipating provider is a medical provider who does not have a contract with a particular health insurance company or network. If you use a nonparticipating provider, you will generally pay a larger portion of the bill. In some cases, you may be responsible for the entire bill.Limited benefit plansThese are not considered to be comprehensive medical insurance plans. Instead, they provide very specific, limited benefits for different types of services. For example, they may provide a flat rate for each day you stay in the hospital or pay a limited amount for each surgical procedure that you have.Typically, they are marketed toward people who cannot afford or are unable to obtain more comprehensive coverage due to pre-existing health conditions. Or, they may be geared toward people who have high-deductible plans. The good thing about these plans is that they generally pay in addition to any other coverage you may have. Therefore, no coordination of benefits is required.If this is your only coverage, be aware that you will usually have to pay a large portion of any bill as these limited plans do not usually pay large amounts per day. For example, it may actually cost you $1000 a day to stay in the hospital. If your limited benefit plan pays you $200 a day for each day you spend in the hospital, you will be personally responsible for the remaining $800 per day.Medicare supplement plansPeople who have Medicare often choose to purchase a Medicare supplement plan as Medicare does not usually cover medical charges in full. Medicare continues to change and add new options but, in general, a supplemental plan pays the balance of the medical charges after Medicare pays its portion. For example, most Medicare supplements will pick up the Medicare deductible.Some policies also pay for some of the charges that Medicare may not cover. There are many different policy variations. If you are not sure what you are purchasing, consider contacting a broker that assists senior citizens.

The Big List of Health Insurance Companies

In the past health was not much of a political issue. People breathed fresh air tried to eat healthy fruits & vegetable that grew naturally with the use of organic fertilizers and used what medicines were available.But today people usually use non-organic fertilizers and use those with chemicals on them. Also one of the contributing factor which affects people’s health is pollution, people barely breathe fresh air in the city. They have to go to the mountains or the country to breathe fresh air. Today people are becoming aware and concerned about their health, especially when there was a SARS and H1N1 virus outbreak in the country which reach the other country.Health insurance may be very expensive yet it is also very important for it deals with you and your family’s health which could later lead to your death if it is not given medical attention. Having your whole family covered in a health plan will also give you peace of mind for you know that when one of your family members gets sick the insurance company will help you pay for the bills.Health insurance is expensive because many of our medicines are also getting expensive. But if you are planning to get a health plan then you should first see what your budget is. You can find insurance plans that fit your budget and gives you the medical needs that suits you and your family.Here is a list of some Health Insurance Companies that provide service in the United States. This is not an exhaustive list but should provide some idea of where to look for individual private coverage. America Medical Security, Inc.
Oregon Health Insurance
Independent Blue Cross, Philadelphia
Community Health Plan of Washington
WPS Health Insurance
Southeastern Indiana Health Organization
ViaHealth Managed Care Services
Affinity Health Plan
Independent Health
CarePlus Health Plan
MedAmerican Insurance Company
American Family Mutual Insurance Company
UNICARE Insurance Company
Botsford Health Plan
American National Insurance Company
Vista Health Plan
Harvard Pilgrim Health Care
Oxford Health Plans, Inc.
UnitedHealth Group, Inc.
Sentara HealthcareListed above are only few of the many health care providers in our country. If you decided to buy a health insurance then make sure that the insurance company is approved by your state government.This is so that you won’t be deceive by the fake companies, especially when you are planning to buy your coverage online. There are many good to be true health insurance that are offered online but don’t jump to it right away so that you won’t be one of the many victim who paid for that insurance that does not exists.Make sure that if you purchase any insurance you purchase it from a reputable insurance company just to be safe.

Determining the Function of an Occupational Health Advisor and How to Evaluate Success

Those responsible for the management of health, environment and safety matters should consider the following guidance when determining what function the occupational health nurse specialist will fulfill within the company. There may well be variation in the function of an occupational health nurse between different organizations depending on the needs and priorities of the working population and the health care system in which they are operating. Some useful questions to consider are:Has a comprehensive health needs assessment been performed recently to identify the needs of the organization and to help with setting priorities for action?
Has the workplace health management policy been reviewed and agreed in light of the needs assessment, taking into account both legislative demands and voluntary agreements?
Have the goals of the occupational health service been defined clearly and communicated throughout the organization?
Does the occupational health service have adequate resources to achieve these goals, including staff, expertise, facilities and management support?
Is it clear how the performance of the occupational health service or of individual professionals within that service, is to be evaluated and are there clear, objective criteria agreed?The answers to each of these questions will help to shape the discussion about the role and function of the occupational health nursing specialist within a specific organization.Workplace health management is most effective when there is:Commitment from senior management
Active participation of employees and trade unions
Integration of company policies and clear targets for HES (health, environment and safety management)
Effective management processes and procedures
Adequate resources
A high level of management competence, and
Rigorous monitoring of company performance using the principles of continuous quality improvement.Policy making should be based on legislation and on a voluntary agreement between social partners at work, covering the total concept of health, safety and wellbeing at work.Evaluation of PerformanceEvaluation can take place on three levels:Company performance in the area of workplace health management
Contribution of the occupational health and safety service
Contribution of the individual occupational health nurseAll review procedures should be based on the principles of continuous quality improvement or audit. The criteria and indicators against which performance is to be measured should be defined clearly as a part of the initial planning and contracting process so that everyone is clear about what performance indicators are being used. Some caution is required if health measures are to be used as performance indicators for the occupational health service as much of the work of an occupational health service is orientated primarily towards the prevention of disease or injury or the reduction of risk. The success or failure of preventative strategies can be difficult to measure using health data on its own as it is sometimes uncertain to what extent a single intervention or programme of interventions can claim responsibility for preventing the effect. Furthermore, many health effects only become apparent a long time after initial exposure and sometimes only become apparent in particularly vulnerable individuals. Where prevention is dependent upon the employee, the line manager or the organization following the advice of the occupational health professional, where this is not followed the adverse event may not necessarily indicate a failure on the part of the occupational health service, but rather a failure of the individual, manager or organization to respond appropriately to the advice they were given.Evaluation can be based on the structure, input, process, output and outcome indicators, and both direct and indirect effects, positive or negative, can be taken into account when judging the relative success or failure of the service. It is often useful to consider two inter-related aspects of occupational health practice in the evaluation process, the professional standards that underpin professional practice and the delivery or services within the organization. Professional practice can be evaluated by, for example, evidence of participating in continuing professional development and adapting practices to take account of new knowledge, self-assessment of compliance with current best practice guidelines, regular internal and external peer review, or systematic audit of compliance with standards. The criteria used to evaluate professional practice should also take account of ethical standards, codes of practice and guidance from the professional bodies. Evaluating service delivery can be done by, for example, comparing the delivery of services against predetermined service level agreements or contracts, including meeting agreed quality standards for services, through customer or client satisfaction surveys, or by assessing the adequacy of access to and level of uptake of services.