| Coinsurance |
| The amount you are required to pay after you have met your deductible. The coinsurance rate is usually an expressed percentage. Example: If the insurance company pays 80% of the claim. You pay 20%. |
| Co-payment or Co-pay |
| Refers to the payment that must be made at the time of service for Physician Office Visits |
| Deductible |
| Is a specified dollar amount which must be paid by the covered individual in each deductible accumulation period before payment of benefits will be made by the insurance company. |
| Emergency Services |
| Services provided within 48 hour of an injury or medical emergency. |
| Exclusions |
| Specific conditions or circumstances for which the policy will not provide benefits. |
| Medical Emergency |
| The sudden onset of a medical condition with acute symptoms of severity that the absence of immediate medical condition could result in:A) permanently placing the patients health in jeopardy; B) causing other serious medical consequences; C) causing serious impairment to bodily functions; D) causing serious and permanent dysfunctions to any body part; |
| Medical Necessary |
| Describes health care treatments, services or supplies which are appropriate and consistent with the diagnosis and treatment of a medical condition according to generally accepted medical standards. |
| Out-of-pocket expenses |
| Refers to the amount a covered person will have to pay “Out of their pocket” in a calendar year. |
| Pre-existing condition |
| Condition for which a person received medical care, treatment, services, medication, diagnosis, or consultation 12 months prior to the insured person’s effective date of coverage or a condition that produced symptoms that are distinct and significant enough to establish the onset of a condition or that the condition manifested itself, where a person learned in medicine would be able to diagnose the condition because of those symptoms. |
| Premium |
| The amount you pay in exchange for insurance coverage. |
| Provider |
| Any person (Doctor, Nurse, Dentist) or institution (hospital or clinic) that provides medical care. |
