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FAQ's

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24 Hour Approval: "24 Hour Approval" is a special feature offered on some health insurance plans. When you apply for coverage under plans offering "24 Hour Approval", you can be advised via email of the insurance company's coverage decision within 24 hours.

 

Access: The availability of medical care. The quality of one's access to medical care is determined by location, transportation options, and the type of medical care facilities available in the area, etc..

 

Accident: For health insurance purposes, an accident is an unforeseen, unexpected and unintended event resulting in bodily injury.

 

Accumulation Period: The period of time during which an insured person incurs eligible medical expenses toward the satisfaction of a deductible.

 

Actively-at-work: Most group health insurance policies state that if an employee is not "actively-at-work" on the day the policy goes into effect, the coverage will not begin until the employee returns to work.

 

Actual Charge: The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.

 

Actuary:A person professionally trained in the mathematical and statistical aspects of the insurance industry.

Actuaries frequently calculate premium rates, reserves and dividends and assist in estimating the costs and savings of benefit changes.

 

Acupuncture: Typicablly, acupuncture services include services performed by a licensed acupuncturist.

 

Acute Care: Medical care administered, frequently in a hospital or by nursing professionals, for the treatment of a serious injury or illness or during recovery from surgery. Medical conditions requiring acute care are typically periodic or temporary in nature, rather than chronic.

 

Additional Drug Benefit List: see Drug Maintenance List.

 

Administrative Services Only (ASO) Agreement: A business contract under which an insurance company agrees to perform specific administrative duties for the maintenance of a self-funded health insurance plan.

 

Admissions/1,000: A statistic used by health insurance companies describing the number of hospital admissions for each 1000 persons covered under a health insurance plan within a given time period.

 

Admits: Hospital admissions. A term used to describe the number of persons admitted to a hospital within a given period.

 

Adverse Selection: The tendency of those who experience greater health risks to apply for and continue their coverage under any given health insurance plan. When adverse selection increases, health insurance companies experience greater expenses and may raise rates.

 

Age Change: For insurance purposes, this is the date on which a person's age changes. Note that this may not correspond with the individual's actual birthday, but may fall midway between birthdays. An age change may result in an increase in rates.

 

Age Limits: Ages below and above which an insurance company will not accept applications or renew policies.

 

Age/Sex Factor: A factor employed by insurance companies in the underwriting process, used to determine a group's risk of incurring medical costs, based on the ages and genders of the persons in that group.

 

Agent: A state-licensed individual or entity representing one or more insurance companies. An agent solicits and facilitates the sale of insurance contracts or policies and provides services to the policyholder on behalf of the insurer. See also, Broker.

 

Allied Health Personnel: Also referred to as paramedical personnel, these are health workers (often licensed) who perform duties that would otherwise be performed by physicians, optometrists, dentists, podiatrists, nurses and chiropractors.

 

Allowable Charge: -also referred to as the Allowed Amount, Approved Charge or Maximum Allowable. See also, Usual, Customary and Reasonable Charge. This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. The Allowable Charge is typically a discounted rate rather than the actual charge.

 

It may be helpful to consider an example: You have just visited your doctor for an earache. The total charge for the visit comes to $100. If the doctor is a member of your health insurance company's network of providers, he or she may be required to accept $80 as payment in full for the visit - this is the Allowable Charge. Your health insurance company will pay all or a portion of the remaining $80, minus any co-payment or deductible that you may owe. The remaining $20 is considered provider write-off. You cannot be billed for this provider write-off. If, however, the doctor you visit is not a network provider then you may be held responsible for everything that your health insurance company will not pay, up to the full charge of $100.

This term may also be used within a Medicare context to refer to the amount that Medicare considers payment in full for a particular, approved medical service or supply.

 

Allowable Costs: Charges for healthcare services and supplies for which benefits are available under your health insurance plan.

 

Allowed Amount: -see Allowable Charge.

 

Alternate Delivery System: Healthcare services or facilities which "deliver" care that is more cost-effective than that provided in a hospital. Alternate Delivery Systems may include skilled nursing facilities, hospice programs and home health care services.

 

Alternative Medicine: Any medical practice of form of treatment not generally recognized as effective by the medical community at large. Alternative medicine may encompass a broad range of services and practices including acupuncture, homeopathy, aromatherapy, naturopathy, etc.. Many insurance companies do not provide coverage for these services.

 

Ambulatory Care: Medical care rendered on an outpatient basis and which may include diagnosis, certain forms of treatment, surgery and rehabilitation. See also, Ambulatory Setting.

 

Ambulant service: Means service that is performed in a facility approved under the Health Practice Law (2013 Revision) on a patient who enters and leaves the facility after recovery, within twenty-four hours and includes outpatient radiation, chemotherapy and surgical services and procedures conducted in an ambulant facility.

 

Ambulatory Setting: Medical facilities such as surgery centers, clinics and offices in which healthcare is provided on an outpatient basis.

 

Ancillary Fee: An extra fee sometimes associated with obtaining prescription drugs which are not listed on a health insurance plan's formulary of covered medications.

 

Ancillary Products: Additional health insurance products (such as vision or dental insurance) that may be added to a medical insurance plan for an additional fee.

 

Ancillary Services: Supplemental healthcare services such as laboratory work, x-rays or physical therapy that are provided in conjunction with medical or hospital care.

 

Annual limit: Many health insurance plans place dollar limits upon the claims the insurer will pay over the course of a plan year. Beginning September 23, 2010, PPACA phases annual dollar limits will be phased out over the next 3 years until 2014 when they will not be permitted for most plans. There is an exception to this phase out for Grandfathered Plans. Except for Grandfathered Plans, beginning September 23, 2012 annual limits can be no lower than $2 million. Except for Grandfathered Plans, beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited.

 

Application Fee: The health insurance company may require a one-time application fee. Some insurance companies may refund this fee if the application is not approved. See More Insurance Plan Details section for additional information.

 

Approved Charge: -see Allowable Charge.

 

Approved Health Care Facility or Program: A medical facility or healthcare program (often organized through a hospital or clinic) that has been approved by a health insurance plan to provide specific services for specific conditions.

 

Assignment of Benefits: The payment of health insurance benefits to a healthcare provider rather than directly to the member of a health insurance plan.

 

Attending Physician Statement (APS): A physician's assessment of a patient's state of health as outlined in office notes and test results compiled by the physician. An APS may be requested by an insurance company in lieu of a medical examination in order to determine the state of a health insurance applicant's health for underwriting purposes.

 

Balance Billing: The amount you could be responsible for (in addition to any co-payments, deductibles or coinsurance) if you use an out-of-network provider and the fee for a particular service exceeds the allowable charge for that service.

 

Basic Hospital Expense Insurance: -see Hospitalization Insurance.

 

Bed Days/1,000: A statistic used by health insurance companies describing the number of inpatient hospital days for each 1000 persons covered under a health insurance plan within a given time period.

 

Benefit: A general term referring to any service (such as an office visit, laboratory test, surgical procedure, etc.) or supply (such as prescription drugs, durable medical equipment, etc.) covered by a health insurance plan in the normal course of a patient's healthcare.

 

Benefit Level: The maximum amount a health insurance company agrees to pay for a specific covered benefit.

 

Benefit Package: A description of the healthcare services and supplies that a health insurance company covers for members of a specific health insurance plan.

 

Benefit Riders: This term may be used to describe ancillary products purchased in conjunction with a medical insurance plan.

 

Benefit Year: The annual cycle in which a health insurance plan operates. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall.

 

Binding Receipt: When you submit an application for health insurance and include an initial payment, the health insurance company may provide you with a binding receipt. A binding receipt indicates that, if coverage is approved, the health insurance company is required to initiate coverage from the date on which payment was received.

 

Birthday Rule: One method used by health insurance companies to determine which parent's health insurance coverage will be primary for a dependent child, when both parents have separate coverage. Typically, the health insurance plan of the parent whose birthday falls earliest in the year will be considered primary. For more information, see also, COB.

 

Board-certified: A board-certified physician is one that has successfully completed an educational program and evaluation process approved by the American Board of Medical Specialties, including an examination designed to assess the knowledge, skills and experience required to provide quality patient care in a specific specialty.
Broker: Though sometimes used in a sense synonymous with the term agent, a broker typically works to match applicants with a health insurance company or plan best matched to their needs. The broker is paid a commission by the insurance company, but represents the applicant rather than the insurance company itself.

 

Business License: A license from a governmental agency authorizing an individual or an employer to conduct business.

 

Business Structure: A state-designated legal structure that governs business taxes, liability, and operational requirements. Examples include: sole proprietorship, partnership, corporation, or LLC.

COB (Coordination of Benefits): This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy. See also, Non-duplication of Benefits.

 

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985): Federal legislation allowing an employee or an employee's dependents to maintain group health insurance coverage through an employer's health insurance plan, at the individual's expense, for up to 18 months in certain circumstances. COBRA coverage may be extended beyond 18 months in certain circumstances. COBRA rules typically apply when an employee loses coverage through loss of employment (except in cases of gross misconduct) or due to a reduction in work hours. COBRA benefits also extend to spouses or other dependents in case of divorce or the death of the employee. Children who are born to, adopted, or placed for adoption with the covered employee while he or she is on COBRA coverage are also entitled to coverage. All companies that have averaged at least 20 full-time employees over the past calendar year must comply with COBRA regulations.

 

Capitation: A method of compensation sometimes employed by health insurance companies, in which payment is made to a healthcare provider on a per-patient rather than a per-service basis.

 

For example, under capitation an HMO doctor may be paid a fixed amount each month to serve as the primary care physician for a specific number of HMO members assigned to his or her care, regardivess of how little or how much care each member needs.

 

Carrier: Any insurer, managed care organization, or group hospital plan, as defined by applicable state law.

 

Carry-over Provision: A provision of some health insurance plans allowing medical expenses paid for by the member in the last three months of the year to be carried over and applied toward the next year's deductible.

 

Case Management: When a member requires a great deal of medical care, the health insurance company may assign the member to case management. A case manager will work with the patient's healthcare providers to assist in the management of the patient's long-term needs, with appropriate recommendations for care, monitoring and follow-up. A case manager will also help ensure that the member's health insurance benefits are being properly and fully utilized and that non-covered services are avoided when possible.

 

Centers for Medicare and Medicaid Services: Formerly known as the Health Care Financing Administration, the Centers for Medicare and Medicaid Services (CMS) is part of the federal government's Department of Health and Human Services, and is responsible for the administration of the Medicare and Medicaid programs. The CMS establishes standards for healthcare providers that must be complied with in order for providers to meet certain certification requirements.

 

Certificate of Coverage: A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company.

 

Chemical Dependency Inpatient: Typically, chemical dependency inpatient services include services relating to the treatment of a chemical dependency that requires a stay at a hospital or other medical facility.

 

Chiropractic: Typically, chiropractic services include services provided by a licensed chiropractor.

 

Chronic: In healthcare and insurance terminology, a chronic condition is one that is permanent, recurring or long lasting, as opposed to an acute condition.

 

Claim: A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider.

 

Coinsurance: The amount that you are obliged to pay for covered medical services after you've satisfied any co-payment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a healthcare provider.

 

For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance.

 

Company: The insurance company that is offering this health insurance plan.

 

Commission: Means the Health Insurance Commission established under section 3 of the Health Insurance Commission Law (2010 Revision);

 

Cost-sharing: Health care provider charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance, and co-payments. Balance-billed charges from out-of-pocket physicians are not considered cost-sharing. Beginning in 2014, PPACA limits total cost-sharing to $5,950 for an individual and $11,900 for a family. These amounts will be adjusted annually to reflect the growth of premiums.

 

Co-payment: A specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a "co-pay." For example, your health insurance plan may require a $15 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.

 

Current Procedural Terminology: (CPT) Means a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians, which terms and codes are published by the American Medical Association.

 

Date of Service: The date on which a healthcare service was provided.

 

Deductible: A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most Indemnity and PPO plans do.

 

Deductible Carry-over Credit: -see, Carry-over Provision

 

Department of Health and Human Services: A department of the federal government responsible for certain social service functions, such as the administration and supervision of the Medicare program.

 

Dependent Coverage: Health insurance coverage extended to the spouse and unmarried children of the primary insured member. Certain age restrictions on the coverage of children may apply.

 

Designated Mental Health Provider: An organization hired by a health insurance plan to provide mental health and/or substance abuse treatment services.

 

Drug Formulary: A list of prescription medications selected for coverage under a health insurance plan. Drugs may be included on a drug formulary based upon their efficacy, safety and cost-effectiveness. Some health insurance plans may require that patients obtain preauthorization before non-formulary drugs are covered. Other health insurance plans may require that a patient pay a greater share or all of the cost involved in obtaining a non-formulary prescription.

 

Drug Maintenance List: A list of commonly prescribed drugs intended for patients' ongoing or long-term use.

 

Drug Utilization Review (DUR): The process by which health insurance companies evaluate or review the use of prescription drugs for appropriateness in the treatment of a patient.

 

Durable Medical Equipment (DME): Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc.. Coverage levels for DME often differ from coverage levels for office visits and other medical services.

 

ERISA (Employment Retiree Income Security Act of 1974): Federal legislation designed to protect the rights of retirees and beneficiaries of benefit plans offered by employers.

 

Effective Date: The date on which health insurance coverage comes into effect.

 

Eligibility Date: The date on which a person becomes eligible for insurance benefits.

 

Eligibility Requirements: Conditions that must be met in order for an individual or group to be considered eligible for insurance coverage.

 

Eligible Dependent: A dependent (usually spouse or child) of an insured person who is eligible for insurance coverage.

 

Eligible Employee: An employee who is eligible for insurance coverage based upon the stipulations of the group health insurance plan.

 

Eligible Expenses: Expenses defined by the health insurance plan as eligible for coverage.

 

Eligible Person: This term is used to designate a person who is eligible for insurance coverage even though he or she may not be an employee, but rather a member of an organization or union.

 

Emergency Room: Typically, emergency room services include all services provided when a patient visits an emergency room for an emergency condition. An emergency condition is any medical condition of recent onset and severity, including but not limited to severe pain, that would lead to a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organ or part.

 

Employee Certificate of Insurance: -see Certificate of Coverage.

 

Employee Contribution: The portion of the health insurance premium paid for by the employee, usually deducted from wages by the employer.

 

Employer Contribution: The portion of an employee's health insurance premium paid for by the employer.
Employer Wage and Tax Statement: An employer tax reporting statement submitted to the applicable governmental agency to establish and report the employer's tax responsibilities.

 

Enrollee: An eligible person or eligible employee who is enrolled in a health insurance plan. Dependents are not referred to as enrollees.

 

Enrollment: The process through which an approved applicant is signed up with the health insurance company and coverage is made effective. This term may also be used to describe the total number of enrollees in a health insurance plan.

 

Enrollment Period: The period of time during which an eligible employee or eligible person may sign up for a group health insurance plan.

 

Episode of illness: Includes any period during which a person receives medical treatment for an illness within sixty days of any previous treatment for the same illness.

 

EPO(Exclusive Provider Organization): An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. There are no out-of-network benefits.

 

Essential Benefits: PPACA requires all health insurance plans sold after 2014 to include a basic package of benefits including hospitalization, outpatient services, maternity care, prescription drugs, emergency care, and preventive services among other benefits. It also places restrictions on the amount of cost-sharing that patients must pay for these services.

 

Estimated Cost: The amount quoted is an estimated cost of the health plan, which is subject to change during the enrollment process of the health plan, the optional benefits you selected, if any, and other relevant factors. It may be the sum of estimated premiums and other recurring charges, if the insurance company has such charges.

 

Evidence of Coverage: -see Certificate of Coverage.

 

Evidence of Insurability: When applying for an individual health insurance plan, an applicant may be asked to confirm his or her health condition in writing, through a questionnaire or through a medical examination. When applying for group health insurance, evidence of insurability is only required in specific cases (for instance, when a person fails to enroll in the group plan during the enrollment period).

 

Examination: In health insurance usage, this generally refers to a medical examination performed as part of an application for a life or health insurance plan. See, Evidence of Insurability.

 

Exclusions: Specific conditions, services or treatments for which a health insurance plan will not provide coverage.

 

Experimental or Investigational Procedures: Any healthcare services, supplies, procedures, therapies or devices the effectiveness of which a health insurance company considers unproven. These services are generally excluded from coverage.

 

Explanation of Benefits (EOB): A statement sent from the health insurance company to a member listing services that were billed by a healthcare provider, how those charges were processed, and the total amount of patient responsibility for the claim.

 

Extended Coverage: A provision of some health insurance plans allowing for coverage of certain healthcare services after the member is no longer covered on the plan. For example, a member's maternity benefits may be extended beyond the expected end of coverage if the woman was already receiving covered maternity services.

 

Extension of Benefits: A provision of some health insurance plans allowing for coverage to be extended beyond a scheduled termination date. The extended coverage is made available only when the member is disabled or hospitalized as of the intended termination date, and continues only until the patient leaves the hospital or returns to work.

 

Fees: Includes any fees or charges prescribed to be paid by patients of health care facilities for treatment, nursing, accommodation, attendance, food, dressings, drugs, medicines or other supplies or services rendered to such patients by the health care facilities.

 

Fee-For-Service Plan: -see Indemnity Plan.

 

Fictitious Business Name Statement: A certificate provided by a local or state governmental office that clarifies the true owner of a business or company. When a company or individual conducts business under an assumed name, this is referred to as a "fictitious name." It may also be referred to as a "trade name" or "doing-business-as (DBA)" name. For the purposes of group health insurance, this statement confirms the identity of the business applying for coverage with a health insurance company.

 

Formulary: -see Drug Formulary.

 

Gatekeeper: A term used to describe the role of the primary care physician in an HMO plan. In an HMO plan, primary care physicians serves as the patient's main point of contact for healthcare services and refer patients to specialists for specific needs.

 

Generic Drug: A drug which is exactly the same as a brand name prescription drug, but which can be produced by other manufacturers after the brand name drug's patent has expired. Generic drugs are usually less expensive than brand name drugs.

 

Grace Period: A time period after the payment due date, during which insurance coverage remains in force and the policyholder may make a payment without penalty.

 

Grandfathered plan: Health insurance coverage that existed as of March 23, 2010 that is subject only to certain provisions of the PPACA. Any policy sold in the individual health insurance market after March 23, 2010 will not be grandfathered even if the product sold was offered before that date. New employees may be added to group plans that are grandfathered, and new family members may be added to all grandfathered plans. If you're not sure whether you have a Grandfathered plan, please contact the plan directly.

 

Grievance Procedure: The procedure by which a member or healthcare provider is allowed to file a complaint with a health insurance company and seek a remedy.

 

Group: A number of individuals covered under a single health insurance contract, usually a group of employees.
Group Health Insurance: A health insurance plan that provides benefits for employees of a business or members of an organization, as opposed to individual and family health insurance.

 

Guaranteed Issue: A term used to describe insurance coverage that must be issued regardivess of health status. In most states, group health insurance plans are often described as guaranteed issue plans, because a health insurance company generally cannot refuse coverage to a qualifying business or organization based on the health status of their employees or members. In some states, all health insurance plans are guaranteed issue.

 

Guaranteed Renewable Contract: A contract under which the insured person has the right (usually up to a certain age) to renew and continue his or her health insurance policy by the timely payment of premiums.
HIPAA (Health Insurance Portability and Accountability Act of 1996): Legislation mandating specific privacy rules and practices for medical care providers and health insurance companies, designed to streamline the healthcare and insurance industries and to protect the privacy and identity of healthcare consumers. HIPAA also provides additional protections for consumers, designed to help them obtain or retain health insurance coverage in certain circumstances. For more information on HIPAA rules and regulations, visit the Centers for Medicare and Medicaid Services website at http://www.cms.hhs.gov.

 

HMO: HMO means "Health Maintenance Organization." HMO plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO, or who agree to provide services to members at a pre-negotiated rate. As a member of an HMO, you will need to choose a primary care physician ("PCP") who will provide most of your health care and refer you to HMO specialists as needed. Some HMO plans require that you fulfill a deductible before services are covered. Others only require you to make a copayment when services are rendered. Health care services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency. 

 

An HMO may be right for you if:

  • You're willing to play by the rules and coordinate your care through a primary care physician
  • You're looking for comprehensive benefits at a reasonable monthly premium
  • You value preventive care services: coverage for checkups, immunizations and similar services are often emphasized by HMOs

 

HSA (Health Savings Account): A tax advantaged savings account to be used in conjunction with certain high-deductible (low premium) health insurance plans to pay for qualifying medical expenses. Contributions may be made to the account on a tax-free basis. Funds remain in the account from year to year and may be invested at the discretion of the individual owning the account. Interest or investment returns accrue tax-free. Penalties may apply when funds are withdrawn to pay for anything other than qualifying medical expenses. Click here for more information on HSAs.

 

Health Care Financing Administration (HCFA): See the Centers for Medicare and Medicaid Services.

 

Health Service Agreement: An agreement between an employer and a health insurance company outlining benefits, enrollment procedures, eligibility standards, etc.

 

High Deductible Health Plan (HDHP): A type of health insurance plan that, compared to traditional health insurance plans, requires greater out-of-pocket spending, although premiums may be lower. In 2012, an HSA-qualifying HDHP must have a deductible of at least $1,200 for single coverage and $2,400 for family coverage. The plan must also limit the total amount of out-of-pocket cost-sharing for covered benefits each year to $6,050 for single coverage and $12,100 for families. In 2013, an HSA-qualifying HDHP must have a deductible of at least $1,250 for single coverage and $2,500 for family coverage. The plan must also limit the total amount of out-of-pocket cost-sharing for covered benefits each year to $6,250 for single coverage and $12,500 for families.
Home Health Agency: A certified healthcare agency that provides home health care services. See, Home Health Care.

 

Home Health Care: Part-time care that is provided by medical professionals in the home setting rather than in a hospital or skilled nursing facility.

 

Hospice Care: Care rendered either on an inpatient basis or in the home setting for a terminally ill patient. Often referred to as "palliative" or "supportive" care, hospice care emphasizes the management of pain and discomfort and the emotional support of the patient and family. See also, Respite Care.

 

Hospital Benefits: Benefits payable for hospital room and board and other miscellaneous charges resulting from hospitalization.

 

Hospitalization: Typically, hospitalization services include services related to staying at a hospital for either scheduled procedures, accidents or medical emergencies. Hospitalization services typically do not include hospital stays for giving birth to a child.

 

Hospitalization Insurance: Insurance intended to provide coverage in case of hospitalization, including benefits for room and board and miscellaneous expenses, within certain limitations.
IPA (Individual Practice Association): An organization of physicians who may maintain separate offices but who negotiate contracts with insurance companies and medical facilities as a group. Some health insurance applications will ask you to provide your primary care physician's IPA number. It can usually be found in the health insurance plan's online directory.

 

In-area Services: Healthcare services rendered within a health insurance plan's coverage area.

 

Incontestable Clause: A provision in an insurance policy that states that the validity of the insurance contract cannot be contested after two (or sometimes three) years.

 

Indemnity Plan: Also called "fee-for-service" plans, Indemnity plans typically allow you to direct your own health care and visit whatever doctors or hospitals you like. The insurance company then pays a set portion of your total charges. You may be required to pay for some services up front and then apply to the insurance company for reimbursement. Indemnity plans typically require that you fulfill an annual deductible. Because of the freedom they allow members, Indemnity plans are sometimes more expensive than other types of plans.

 

An Indemnity plan may be right for you if:

  • You want the greatest level of freedom possible in choosing which doctors or hospitals to visit
  • You don't mind coordinating the billing and reimbursement of your claims yourself

 

Individual and Family Health Insurance: A type of health insurance purchased by an individual or family, independent of any employer group or organization.

 

Infertility: Typically, infertility services include any medical services, both inpatient and outpatient, to assist with the conception of child.

 

Inpatient: A term used to describe a person admitted to a hospital for at least 24 hours. It may also be used to describe the care rendered in a hospital when the duration of the stay is at least 24 hours.

 

Integrated Delivery System: A group of doctors, hospitals and other providers who work together to deliver a broad range of healthcare services.

 

Intermediate Care: A level of nursing care, considered less intensive than skilled nursing care, but which may be rendered in a skilled nursing or intermediate care facility.

 

Lab/X-Ray: Typically, lab/x-ray is any diagnostic lab test or diagnostic/therapeutic x-ray performed in support of basic health services. Lab services typically include services like blood panels and urinalysis. X-ray services typically include basic outpatient skeletal or other plain film x-ray, outpatient ultrasound, GI series, MRI, and CT scan. Prostate cancer screening, mammograms, and pap smears may be covered by Lab/X-Ray benefit, or they may be covered by Periodic OB-GYN benefit or Preventative Care benefits. Typically, dental x-rays are not included in Lab/X-ray benefits.

 

Lapse: The termination of insurance coverage due to lack of payment after a specific period of time.

 

Length of Stay (LOS): The total number of days that a patient stays in a facility such as a hospital.

 

Lifetime Limit: Many health insurance plans place dollar limits upon the claims that the plan will pay over the course of an individual's life. PPACA prohibits lifetime limits on the dollar value of benefits deemed essential by the Department of Health and Human Services, for plan or policy years beginning on Sept. 23, 2010.

 

Lifetime Maximum: Lifetime maximum or lifetime limits refers to the maximum dollar amount that a health insurance company agrees to pay on behalf of a member for covered services during the course of his or her lifetime. For plan or policy years beginning on or after Sept. 23, 2010, plans may not establish any lifetime limit on the dollar amount of benefits for any individual. All plans are required by PPACA to remove the lifetime maximum restrictions.

 

Limitations: A term referring to any maximums that a health insurance plan imposes on specific benefits.

 

Long-term Care: Care provided on a continuing basis for the chronically ill or disabled. Long-term care may be provided on an inpatient basis (at a long-term care facility) or in the home setting.

M through Z

MSA (Medical Savings Account): A tax-advantaged personal savings account used in conjunction with a high-deductible health insurance plan. MSAs are currently being phrased out and replaced with HSAs. See HSA.

 

Major Medical Insurance: A type of medical insurance plan that provides benefits for a broad range of healthcare services, both inpatient and outpatient. Major medical insurance plans often carry a high deductible.

 

Managed Care: A general term used to describe a variety of healthcare and health insurance systems that attempt to guide a member's use of benefits, typically by requiring that a member coordinate his or her healthcare through a primary care physician, or by encouraging the use of a specific network of healthcare providers. The management of healthcare is intended to keep costs -and monthly premiums- as low as possible. There are several different types of managed care health insurance plans, including HMO, PPO, and POS plans

 

Maternity (Inpatient): Typically, inpatient maternity services include hospitalization and physician fees associated with the birth of a child.

 

Maternity (Outpatient): Typically, outpatient maternity services include OB-GYN office visits during pregnancy and immediately after giving birth.

 

Maternity Coverage: Maternity coverage means the insurance covers part or all of the medical cost during a woman's pregnancy. Coverage is broken down into inpatient and outpatient services. Typically, inpatient coverage includes hospitalization and physician fees associated with child birth. Outpatient coverage pays for prenatal and postnatal OB-GYN office visits.

 

Maximum Allowable: see Allowable Charge.

 

Max Duration: Maximum duration is the longest coverage period offered by the plan.

You should choose a plan which has a coverage period which will safely cover your insurance needs while you are waiting for a standard long-term policy to begin. You should apply for short-term coverage only if you know with certainty that you will have standard, long-term coverage (or coverage through an employer) at a future date.

 

Maximum Out-Of-Pocket Costs: An annual limitation on all cost-sharing for which patients are responsible under a health insurance plan. This limit does not apply to premiums, balance-billed charges from out of network health care providers or services that are not covered by the plan.

 

Medicaid: A state-funded healthcare program for low income and disabled persons.

 

Medical Necessity: A basic criterion used by health insurance companies to determine if healthcare services should be covered. A medical service is generally considered to meet the criteria of medical necessity when it is considered appropriate, consistent with general standards of medical care, consistent with a patient's diagnosis, and is the least expensive option available to provide a desired health outcome. Of course, preventive care services that may be covered under a health insurance plan are not always subject to the criteria of medical necessity.

 

Medicare: A national, federally-administered health insurance program authorized in 1965 to cover the cost of hospitalization, medical care, and some related health services for most people over age 65 and certain other eligible individuals.

 

Medicare Beneficiary: Anyone entitled to Medicare benefits based on the rules for eligibility outlined by the Social Security Administration.

 

Medicare Supplement Insurance: Health insurance provided to an individual or group that is intended to help fill in the gaps in the coverage provided by Medicare.

 

Member: Anyone covered under a health insurance plan, an enrollee or eligible dependent.

 

Mental Health Inpatient: Typically, mental health inpatient refers to services rendered when a patient stays at a hospital or other medical facility for treatment of a mental health condition.

 

Mental Health Office Visits: Typically, mental health office visits include visits to a licensed medical provider for treatment of a mental health condition.

 

National Association of Insurance Commissioners (NAIC): The NAIC is a national association of state officials charged with regulating insurance. The NAIC was formed to help provide some measure of national uniformity in insurance regulation.

 

National Drug Code (NDC): A system employed by healthcare providers and insurance companies for classifying and identifying drugs. Each prescription drug in common use is assigned an NDC number.

 

Network: A "Network" plan is a variation on a PPO plan. With a Network plan you'll need to get your medical care from doctors or hospitals in the insurance company's network if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the network. Services rendered by out of network providers may not be covered or may be paid at a lower level. 

 

A Network plan may be right for you if:

Your favorite doctor already participates in the network (use our Doctor Finder tool to find out)
You want some freedom to direct your own health care but don't mind working within a network of preferred providers

 

Network Provider: A healthcare provider who has a contractual relationship with a health insurance company. Among other things, this contractual relationship may establish standards of care, clinical protocols, and allowable charges for specific services. In return for entering into this kind of relationship with an insurance company, a healthcare provider typically gains in numbers of patients and a primary care physician may receive a capitation fee for each patient assigned to his or her care.

 

Non-duplication of Benefits: -see, COB.

 

Nursing Home: A licensed facility which provides general nursing care to those who are chronically ill or who require constant supervision and assistance with the needs of daily living.

 

Office Visit: An office visit is the amount you pay when you see the doctor or dentist for routine care. 

 

Examples for $100 office visit:

If the plan's office visit is $25, then you pay $25.
If the plan's office visit is 30% before deductible, then you pay $30.
If the plan's office visit is 35% after deductible, then, if you have not yet reached your deductible, you pay $100; if you have reached your deductible you pay $35.

Select higher amounts to lower your monthly premiums.

 

Office Visit (IFP): Typically, an office visit is an outpatient visit to a physician's office for illness or injury.

 

Open Enrollment Period: A time period during which eligible persons or eligible employees may opt to sign up for coverage under a group health insurance plan. During an open enrollment period, applicants typically will not be required to provide evidence of insurability.

 

Out-of-network Care: Healthcare rendered to a patient outside of the health insurance company's network of preferred providers. In many cases, the health insurance company will not pay for these services.

 

Out-of-pocket Costs: -see Maximum Out-of-pocket Costs.

 

Out-of-Pocket Maximum: -see Maximum Out-of-pocket Costs.

 

Outpatient: A term referring to a patient who receives care at a medical facility but who is not admitted to the facility overnight, or for 24 hours or less. The term may also refer to the healthcare services that such a patient receives.

 

Outpatient Surgery: Typically, outpatient surgery is defined as any surgical procedure that does not require an overnight stay in a hospital.

 

Over-the-counter (OTC) Drugs: Drugs that may be obtained without a prescription.

 

POS: POS stands for "Point of Service." POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, and may not be covered at all.

 

A POS plan may be right for you if:
You're willing to play by the rules and possibly coordinate your care through a primary care physician
Your favorite doctor already participates in the network (use our Doctor Finder tool to find out)

 

PPO: PPO means "Preferred Provider Organization." Like the name implies, with a PPO plan you'll need to get your medical care from doctors or hospitals on the insurance company's list of preferred providers if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the PPO. Services rendered by out of network providers may not be covered or may be paid at a lower level. A broad variety of PPO plans are available, many with low monthly premiums.

 

A PPO may be right for you if:

Your favorite doctor already participates in the PPO (use our Doctor Finder tool to find out)
You want some freedom to direct your own health care but don't mind working within a list of preferred providers

 

Part-Time Employee: For the purposes of qualifying for group health insurance, a part-time employee is one working between 20-29 hours per week.

 

Partial Disability: A condition in which, as the result of an illness or injury, a group health insurance member cannot perform all the duties of his or her occupation, but can perform some. Exact definitions differ between health insurance plans.

 

Partial Hospitalization Services: Also referred to as "partial hospital days," this is a healthcare term used to refer to outpatient services performed in a hospital setting as an alternative or follow-up to inpatient mental health or substance abuse treatment.

 

Participating Provider: Generally, this term is used in a sense synonymous with Network Provider. However, not all healthcare providers contract with health insurance companies at the same level. Some providers contracting with insurers at lower levels may sometimes be referred to as "participating providers" as opposed to "preferred providers."

 

Peer Review: This term refers to the process by which a physician or team of healthcare specialists review the services, course of medical treatment, or the conclusions of a scientific medical study conducted by another physician or group of medical experts. Peer review must be provided by a physician or team of medical experts with training and expertise equal to the physician or team conducting the treatment or research in question.

 

Periodic Health Exam: Typically, a periodic health exam is an exam that is occurs on a regular basis for preventative purposes, like a routine physical or annual check-up.

 

Periodic OB-GYN Exam: Typically, a periodic OB-GYN exam is a routine OB-GYN exam that occurs on a regular basis, typically for preventative purposes, like a PAP smear.

 

Physical Therapy: Typically, physical therapy services include rehabilitative services provided by a licensed physical therapist to help restore bodily functions such as walking, speech, the use of limbs, etc.

 

Place of Service: The type of facility in which healthcare services were provided, whether it be the home, hospital, clinic, office, etc..

 

Plan Name: The name of the health plan offered by the insurance company. Below are six (6) examples of Plan Types:

 

Plan Type 1:PPO

PPO means "Preferred Provider Organization." Like the name implies, with a PPO plan you'll need to get your medical care from doctors or hospitals on the insurance company's list of preferred providers if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the PPO. Services rendered by out of network providers may not be covered or may be paid at a lower level. A broad variety of PPO plans are available, many with low monthly premiums.

 

A PPO may be right for you if:

  • Your favorite doctor already participates in the PPO (use our Doctor Finder tool to find out)
  • You want some freedom to direct your own health care but don't mind working within a list of preferred providers

 

Plan Type 2:HMO 

HMO means "Health Maintenance Organization." HMO plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO, or who agree to provide services to members at a pre-negotiated rate. As a member of an HMO, you will need to choose a primary care physician ("PCP") who will provide most of your health care and refer you to HMO specialists as needed. Some HMO plans require that you fulfill a deductible before services are covered. Others only require you to make a copayment when services are rendered. Health care services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency.

 

An HMO may be right for you if:

  • You're willing to play by the rules and coordinate your care through a primary care physician
  • You're looking for comprehensive benefits at a reasonable monthly premium
  • You value preventive care services: coverage for checkups, immunizations and similar services are often emphasized by HMOs

 

Plan Type 3: Network 

A "Network" plan is a variation on a PPO plan. With a Network plan you'll need to get your medical care from doctors or hospitals in the insurance company's network if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the network. Services rendered by out of network providers may not be covered or may be paid at a lower level.

 

A Network plan may be right for you if:

  • Your favorite doctor already participates in the network (use our Doctor Finder tool to find out)
  • You want some freedom to direct your own health care but don't mind working within a network of preferred providers

 

Plan Type 4: POS 

POS stands for "Point of Service." POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, and may not be covered at all.

 

A POS plan may be right for you if:

  • You're willing to play by the rules and possibly coordinate your care through a primary care physician
  • Your favorite doctor already participates in the network (use our Doctor Finder tool to find out)

 

Plan Type 5: Indemnity 

Also called "fee-for-service" plans, Indemnity plans typically allow you to direct your own health care and visit whatever doctors or hospitals you like. The insurance company then pays a set portion of your total charges. You may be required to pay for some services up front and then apply to the insurance company for reimbursement. Indemnity plans typically require that you fulfill an annual deductible. Because of the freedom they allow members, Indemnity plans are sometimes more expensive than other types of plans.

 

An Indemnity plan may be right for you if:

  • You want the greatest level of freedom possible in choosing which doctors or hospitals to visit
  • You don't mind coordinating the billing and reimbursement of your claims yourself

 

Plan Type 6: EPO (Exclusive Provider Organization). 

An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. There are no out-of-network benefits.

 

Policy Form Number: A unique number that identifies each health insurance policy filed with a state's department of insurance.

 

Policy Term: The period of time for which a health insurance policy provides coverage.

 

PPACA: On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. Legislation (Public Law 111-148), commonly referred to as the health reform law. Among other things, the new law requires that all Americans maintain minimum essential coverage starting in 2014. At that time, health insurance companies will not be able to deny insurance coverage to individuals based on a pre-existing condition.

 

Practical Nurse: A licensed nurse who provides "custodial" care services, such as assistance in walking, bathing, feeding, etc.. Practical nurses do not administer medications or perform other strictly medical services.

 

Pre-Admission Authorization: -see Preauthorization/Precertification #2.

 

Preauthorization/Precertification: These are terms that are often used interchangeably, but which may also refer to specific processes in a health insurance or healthcare context.

 

  1. Most commonly, "preauthorization" and "precertification" refer to the process by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug. Health insurance companies may require that patients meet certain criteria before they will extend coverage for some surgeries or for certain drugs. In order to pre-approve such a drug or service, the insurance company will generally require that the patient's doctor submit notes and/or lab results documenting the patient's condition and treatment history. 

 

  1. The term "precertification" may also be used to the process by which a hospital notifies a health insurance company of a patient's inpatient admission. This may also be referred to as "pre-admission authorization".

 

Pre-existing Condition: A health problem that existed or was treated before the effective date of your health insurance coverage. Most health insurance contracts have a pre-existing condition clause that describes conditions under which the health insurance company will cover medical expenses related to a pre-existing condition. For more information, see also Pre-existing Condition Exclusion.

 

Pre-existing Condition Exclusion: see Pre-existing Condition. In some cases, a health insurance company may exclude a patient's pre-existing conditions from coverage under a new health insurance plan. This is more typical with individual and family health insurance plans and less common with group health insurance plans. HIPAA legislation imposes certain limitations on when a health insurance company can exclude coverage for a pre-existing condition.    PPACA prohibits pre-existing condition exclusions for all plans beginning January 2014 and prohibits pre-existing condition exclusions for all children under the age of 19 in new policies sold on or after September 23, 2010.

 

Premium: The total amount paid to the insurance company for health insurance coverage. This is typically a monthly charge. Within the context of group health insurance coverage, the premium is paid in whole or in part by the employer on behalf of the employee or the employee's dependents.

 

Prescription Medication: A drug that may be obtained only with a doctor's prescription and which has been approved by the Food and Drug Administration.

 

Prescription Drug Coverage: Prescription drug coverage varies by carrier and plan type. Typically, prescription drugs are covered in one of the two ways below:
- Insurance covers a percentage after plan deductible is met.
- Insurance covers cost of the drug but a copay is required with prescription.

 

Preventive benefits: Covered services that are intended to prevent disease or to identify disease while it is more easily treatable. PPACA requires insurers to provide coverage for certain preventive benefits without deductibles, co-payments, or coinsurance. This rule does not apply to Grandfathered Plans. HHS is continuing to update what it defines as Preventative Benefits.

 

Preventive Care: Medical care rendered not for a specific complaint but focused on prevention and early-detection of disease. This type of care is best exemplified by routine examinations and immunizations. Some health insurance plans limit coverage for preventive care services, while others encourage such services. Note that well-baby care, immunizations, periodic prostate exams, pap smears and mammograms, though considered preventive care, may be covered even if your health insurance plan limits coverage for other preventive care services.

 

Primary Care: Basic healthcare services, generally rendered by those who practice family medicine, pediatrics or internal medicine.

 

Primary Care Physician (PCP): A patient may be required to choose a primary care physician (PCP). A primary care physician usually serves as a patient's main healthcare provider. The PCP serves as a first point of contact for healthcare and may refer a patient to specialists for additional services.

 

Primary Coverage: If a person is covered under more than one health insurance plan, primary coverage is the coverage provided by the health insurance plan that pays on claims first. See also, COB.

 

Prior Authorization: -see Preauthorization/Precertification #1.

 

Probationary Period: A waiting period determined by the health insurance company during which coverage for certain pre-existing conditions may be excluded.

 

Provider: A term commonly used by health insurance companies to designate any healthcare provider, whether a doctor or nurse, a hospital or clinic.

 

Provider Write-off: The difference between the actual charge and the allowable charge, which a network provider cannot charge to a patient who belongs to a health insurance plan that utilizes the provider network. See Allowable Charge for more information.

 

Qualifying Event: An event (such as termination or employment, divorce or the death of the employee) that triggers a group health insurance member's protection under COBRA. See COBRA for more information.

 

Risk Rating Process: The process by which a premium or rate for a group or individual is determined. Items that may be considered in the rating process include age, existing diagnosis, historical claims, etc.

 

Reasonable and Customary Charges: -see Usual, Customary and Reasonable (UCR) Charge.

 

Referral: The process through which a patient under a managed care health insurance plan is authorized by his or her primary care physician to a see a specialist for the diagnosis or treatment of a specific condition.
Registered Nurse (RN): A licensed professional nurse with a four-year nursing degree, trained to provide all levels of nursing care including the administration of medication.

 

Renewal: Renewal occurs when a member continues coverage under a health insurance plan beyond the original time frame of the contract. At the end of each benefit year, a plan member is generally invited to renew his or her coverage.

 

Renewal Date: The date on which a member's health insurance plan benefit year renews.

 

Respite Care: Normally associated with hospice care, respite care is a benefit often made available for family members of a patient, providing the patient's primary caretaker with a break or respite from caring for the patient. Respite care may be provided for the patient in either the home or a nursing home setting.

 

Rider: An amendment or modification to an insurance contract. See also, Benefit Riders.

 

Schedule C: The federal tax form used to report business income or business losses. A copy of this form may be required when applying for a group health insurance plan.

 

Schedule K-1: The federal tax form used to report a business partner's share or the income, credits and deductions from a business organized as a partnership. This is submitted to the federal government with the partner's federal tax return. A copy of this form may be required when applying for a group health insurance plan.
Second Surgical Opinion: Some health insurance companies may require a second opinion from a qualified physician or specialist before extending coverage for certain surgical procedures.

 

Secondary Care: Medical care rendered by a specialist (e.g. urologist, cardiologist) rather than a primary care physician. See also Primary Care and Tertiary Care.

 

Secondary Coverage: When a person is covered under more than one health insurance plan, this term describes the health insurance plan that provides payment on claims after the primary coverage. See also Primary Coverage and COB.

 

Self-funded Health Insurance Plan: A health insurance plan that is funded by an employer rather than through a health insurance company. A health insurance company will typically handive the administration of such a plan, but the cost of claims will be paid for by the employer through a fund set up for this purpose. See also, Administrative Services Only (ASO) Agreement.

 

Service Area: The geographic area in which a health insurance plan's benefits are made available. Some health insurance plans will not provide coverage outside of a plan's service area.

 

Short-term Plans: Short-term health insurance plans are similar to individual and family health insurance plans. However, coverage typically extends for no more than 6 months and benefits are often less comprehensive than those provided by a long-term health insurance plan.

 

Skilled Nursing Care: Intensive care usually required around the clock and rendered by, or under the supervision of, a Registered Nurse or licensed Practical Nurse. It is provided only when prescribed by a doctor and usually on an inpatient basis at a hospital or skilled nursing facility. Skilled nursing care may include the administration of medications, tube feeding, the changing of wound dressings, and some types of minor surgery.

 

Small group market: The market for health insurance coverage offered to small businesses - those with between 2 and 50 employees in most states. PPACA will broaden the market to those with between 1 and 100 employees, though until 2016 states may continue to limit small group to 50 employees or less.
Specialist: A doctor who does not serve as a primary care physician, but who provides secondary care, specializing in a specific medical field. See also, Secondary Care.

 

Standard Industrial Classification (SIC) Codes: These are codes used to describe or classify businesses based upon the products or services they provide. When you apply for group health insurance coverage, you may be asked to provide the SIC code for your business. This code provides the insurance company with information about the kind of work your employees are likely to perform and may be used to help determine a monthly premium.

 

Subrogation: The process by which a health insurance company determines whether medical bills should be paid for by the health insurance company itself or by another insurer or third party. For example, claims are frequently subject to subrogation when medical care is rendered as the result of an automobile accident. In most cases the automobile insurer is considered the primary payer. When a health insurance company has determined through the subrogation process that the automobile insurer will no longer pay on medical claims, then the health insurance company will typically become the primary payer.

 

Subscriber: This term may be used in two senses: First, it may refer to the person or organization that pays for health insurance premiums; Secondivy, it may refer to the person whose employment makes him or her eligible for group health insurance benefits.

 

Temporary Partial Disability: This term is used to describe a the condition of a person who due to injury is unable to work at full capacity but who is able to work at reduced efficiency and is expected to fully recover.

 

Temporary Total Disability: This term describes the condition of a person who due to injury is unable to work, but who is expected to fully recover.

 

Tertiary Care: This term is used to describe services rendered by such specialized providers as intensive care units, neurologists, neurosurgeons and thoracic surgeons. Such services frequently require highly sophisticated equipment and facilities.

 

Terminally Ill: In healthcare and insurance usage, this term is used to describe a person who is not expected to live beyond six months due to a specific illness.

 

Treatment Facility: May refer to any facility, either residential or non-residential, which is authorized to provide treatment for mental illness or substance abuse.

 

Triage: A method of classifying sick or injured patients according to the severity of their conditions in order to ensure that medical facilities and staff are most effectively utilized.

 

Underwriting: The process by which an insurer determines whether it will accept an application for insurance based upon risks and projections, and through which a determination on monthly premium is made.
Uniform Billing Code of 1992 (UB-92): The Uniform Billing Code of 1992 set industry-wide standards for medical billing practices.

 

Usual, Customary and Reasonable (UCR) Charge: This refers to the standard or most common charge for a particular medical service when rendered in a particular geographic area. It is often employed in determining Medicare payment amounts.

 

Utilization: This term refers to how frequently a group uses the benefits associated with a particular health insurance plan or healthcare program.

 

Utilization Management/Review: This term is often used to describe a group (or the work performed by a group) of nurses and doctors who work with health insurance plans to determine if a patient's use of healthcare services was medically necessary, appropriate, and within the guidelines of standard medical practice. Utilization Management/Review may also be referred to as Medical Review.

 

Vision Care Coverage: An insurance plan typically offered only on a group basis which covers routine eye examinations and which may also cover all or part of the costs associated with contact lenses or eyeglasses.

 

W-2: The federal tax form used to report an employee's wages and taxes.

 

Waiting Period: A period of time (often 12 months) beginning with your effective date during which your health insurance plan does not provide benefits for pre-existing conditions. This period may be reduced or waived based on any prior health care coverage you had before applying for your new health insurance plan.

 

Waiver (Exclusion Endorsement): An agreement under which a member agrees to waive coverage for specific pre-existing conditions or for specific future conditions.

 

Waiver of Premium: In some cases, a waiver of premium may be granted, allowing a member to maintain health insurance coverage in full force without payment. A waiver of premium is typically only granted in cases of permanent and total disability.

 

Well-Baby/Well-Child Care: Regularly scheduled, preventive care services, including immunizations, provided to children up to an age specified by a health insurance company or mandated by a government agency. HMO and POS plans typically provide coverage for well-baby care, though coverage for these services may be limited under a PPO plan.
PPACA requires health insurers to provide coverage for certain recommended preventive care services, screenings, and immunizations with no cost sharing requirement for plan or policy years beginning on or after September 23, 2010. The Department of Health and Human Services will issue regulations to define what specific benefits are required to be covered under the new law.

 

Well-Woman Care: A term sometimes used by insurance companies and healthcare providers to refer to mammograms and pap smears and other preventive care services rendered to a woman.
PPACA requires health insurers to provide coverage for certain recommended preventive care services and screenings with no cost sharing requirement. The Department of Health and Human Services will issue a ruling to define what specific benefits are required to be covered under the new law.

 

The definitions, examples and explanations contained therein are typical to CINICO and the environment in which we operate. Please note, however, that definitions of certain terms may vary across insurance companies.

 

 

Q: Why can’t I claim back for my car rental and food while overseas on a referral?
A:

This is not a covered benefit.

Q: Do I have overseas benefits?
A:

"Only in a Medical Emergency and you must call the number on the card for approval".

Q: I am now retired and plan to live overseas. Will I be able to use my insurance there?
A:

Only in a medical emergency or if there is a CMO approved referral in place can the insurance be used.

Q: Can I purchase additional benefits to see a private physician?
A:

No, the current plan allows only for services at the CIHSA unless with a CMO approved referral.

Q: How often can I use my Vision benefits (Not SHIC)?
A:

Your benefits are every twenty-four (24) months.

Q: Where can I get my eyes tested?
A:

You can use any of the vision providers on the island.

Q: What are benefits with regards to reproduction, pregnancy and delivery?
A:

Civil Servants are covered 100% with CMO approved referral. Benefits for SHIC plan as outlined in SHIC Plan Details.

Q: What does my policy cover?
A:

A list of policy coverage is available on our website.

Q: Will I be covered for a pre-existing condition, and if so, is there a limit annually or lifetime?
A:

Yes, the Civil Service Plan cover pre-existing conditions and SHIC Plans are risk-rated so a premium is identified based on medical conditions disclosed.

Q: How do I go about replacing a lost or damage CINICO card and how long will it take to get a new one?
A:

You will have to complete a “Replacement Card Form” and pay the fee of KYD $10.00.   The process is five working days.

Q: What does SHIC stand for?
A:

Standard Health Insurance Contract.

Q: Where can I use CINICO?
A:

Only at the CIHSA or with a CMO approved referral to a Private Facility.

Q: Do you cover children under the age of 18?
A:

No, by law all children should be covered as dependents under their parents insurance plan.

Q: Where can I obtain a copy of my plan benefits?
A:

SHIC – plan benefits are available on the website.

Q: Can I purchase travel insurance for non-emergent medical care?
A:

No, currently the plan is not available.

Q: Can my dependent child who is pregnant child (grandchild) be added to my plan?
A:

Yes

Q: What do I need to do to continue coverage for my 18 year old dependent?
A:

You will have to provide proof of full-time education (A letter from the school).

Q: Who is defined as a dependent?
A:

Spouse, biological children, step-children, children whom legal guardianship has been awarded and adopted children.

Q: Can I add my parent/s whom I am caring for as a dependent on my plan?
A:

No.

Q: What is my deductible?
A:

There is no deductible for Civil Servants. Benefits for SHIC as outlined in SHIC Plan Details.

Q: Can my step-children be included as a dependant?
A:

Yes, you may submit legal documentation to you HR Department/Plan Administrator.

Q: How long is my child considered a dependant?
A:

Your child can continue to have coverage as long as he or she is in school from the ages of 18 to 23 years old by submitting a letter to that effect from the school/college/university/facility to your HR Department/Plan Administrator.

Q: What services are offered on your website www.cinico.ky?
A:

a.    We have a multitude of information available in our new website. Once you log in, you will be able to check your claims history, member demographic information and access to our wellness portals! We encourage all of our members to take some time to explore the new wealth resources available on our website.

Q: Is there a limit to what my insurance will pay when referred for treatment overseas?
A:

Civil Servants are covered 100% with CMO approved referral. Benefits for SHIC plan as outlined in SHIC Plan Details.

 

Q: Is there a cost to replace my insurance card if lost or stolen?
A:

Yes, there is a KYD$ 10.00 fee for replacement cards. 

Q: Can I upgrade my policy?
A:

No we only offer 1 standard Health Insurance plan.

Q: Does my policy cover emergency care?
A:

Yes

Q: Can this policy be used overseas?
A:

Yes, with an approved referral from the Chief Medical Officer.

 

Q: Would my new born be automatically covered under my CINICO Plan, and if so, for how long?
A:

New-borns are covered under their mother for 30 days, after which it is the responsibility of their parents/legal guardians to provide documentation to have them added as a dependant.

Q: Can my spouse be covered if they already have private insurance?
A:

Yes, the first insurance company would be considered the Primary Insurance and CINICO would offer secondary coverage.

Q: How long is the process for a new application?
A:

Process is 10-15 working days.

Q: What are the requirements when applying for coverage for my helper?
A:

You will need a complete SHIC application form, Copy of passport (information page) Prove of work permit (update work permit stamp) proof of mailing address (utility bill), and if utility is not in applicant’s name then they would need a letter of permission from the bill holder.

Q: How can I remove a dependant?
A:

You may remove a dependant via your HR Department for Civil Servants or CINICO's office for SHIC members.

Q: How do I obtain coverage for a dependant?
A:

You may submit dependant documentation such as birth certificate, marriage certificate, adoption apapers, etc. to your HR Departement/Plan Adminsitrator for Civil Servants or at CINICO's office for SHIC applicants.

Q: What do I need to include with my application?
A:

Copy of your passport, copy of Immigration status, copy of a utility will with your mailing address.

Q: How long will it take for my policy to be approved?
A:

You will be contacted by a Client Service Manager within 10 to 15 working days of handing in your application.

Q: How do I apply for CINICO coverage?
A:

Online at the CINICO website or obtain the application at a CINICO office.

Q: How long do I have to pay my policy before it is terminated?
A:

You have 30 days from the first of the month, must pay your policy.

Q: How can I reinstate my policy if it was terminated for non-payment?
A:

To reinstate a terminated policy, you are required to pay a reinstatement fee of CI$ 200.00. In addition, you will also have to pay your premium amount for the month you seek reinstatement. CINICO is not responsible, for any claims incurred during the terminated period.  If your policy has been terminated for a period greater than 3 months, CINICO reserves the right to request you complete the application process. 

Q: If my policy is terminated, what do I need in to show that my policy should not have been terminate?
A:

It is imperative that you receive a receipt for EACH of your payments. Producing all your receipts will verify your proof for payments.

Q: How can I cancel my policy?
A:

A self-termination form is available and must be signed off by the policy holder before the end of the month that one requires the termination.

Q: I am not happy with the care received at a certain facility. What do I do?
A:

a.    Please file a complaint with that provider and contact the CINICO Medical Case Management Unit (MCMU) for further assistance. We will bring this to the attention of the provider and, where possible, assist with redirecting your care to an alternative provider.

Q: What is pre-authorization?
A:

a.    Pre-authorization is confirmation that the medical services the facility is about to provide to you has been approved by the insurance company. Therefore, once a local provider receives your Chief Medical Officer (CMO) approved referral, the provider will contact you to confirm an appointment. Once this occurs, the provider must contact the CINICO Medical Case Management Unit (MCMU) between the hours of 9:00am to 4:30pm for preauthorization of services. The MCMU will provide preauthorization for approved services. Should the provider require further services to be provided upon your arrival and assessment, the provider must contact the MCMU for further preauthorization.

b.    Pre-authorization is also required for inpatient admission as the CIHSA.

c.    The CINICO Medical Case Management Unit (MCMU) may be contacted at (345) 949 8101, prompt 2.

Q: I’ve been contacted by a facility/collection agency about outstanding bills! Who should I call?
A:

We do apologize for this inconvenience. For any queries regarding physician or facility claims, please contact the CINICO Claims Team at (345) 949 8101, prompt 3, for assistance.

Q: I have questions about my referral, who should I call?
A:

a.    For any questions relating to your referral for local servcies outside of the CIHSA, please contact the CINICO Medical Case Management Unit (MCMU) to speak with a Medical Case Coordinator at:
        i.    CINICO Medical Case Management Unit
        ii.    Tel: (345) 949 8101, prompt 2, during the business hours of 9:00am – 4:30pm. 
               1.    This number, (345) 949 8101, prompt 1, is available for urgent after hours matters as well that cannot wait until the next business day. Please note, this is not an emergency number. If you are experiencing a medical emergency, please immediately dial 911 for assistance.
        iii.    Email: CaseManagement@cinico.ky 

    b.    For any questions relating to your overseas referral to the United States, please contact our overseas Care Coordinators, MMSI at:
        i.    MMSI, CINICO Oversease Care Coordinators
        ii.    Tel: 1 (855) 733 0103
              1.    This number, 1 (855) 733 0103 is available for any urgent after hours matters as well that cannot wait until the next business day. Please leave a message and a care coordinator will return your call within thirty (30) minutes. Please note, this is not an emergency number. If you are experiencing a medical emergency, please immediately dial 911 for assistance.
        iii.    Email: cinico@mayo.edu 

    c.    For any questions relating to your overseas referral to Jamaica, please contact the CINICO Medical Case Management Unit (MCMU) to speak with a Medical Case Coordinator at:
        i.    CINICO Medical Case Management Unit
        ii.    Tel: (345) 949 8101, prompt 2, during the business hours of 9:00am – 4:30pm. 
              1.    This number, (345) 949 8101, prompt 1, is available for any urgent after hours matters as well that cannot wait until the next business day. Please note, this is not an emergency number. If you are experiencing a medical emergency, please immediately dial 911 for assistance.
        iii.    Email: CaseManagement@cinico.ky 

Q: What happens to my referral after I drop it off at the Referral Office?
A:

a.    Once the CMO approves the referral (approval based on medical necessity and the unavailability of services within the CIHSA), the referral is then sent to the CINICO Medical Case Management Unit (MCMU) to verify that member eligibility, benefits and confirm the services requested are covered by CINICO.

b.    Once this verification is completed, the CINICO MCMU will then send this referral to the appropriate local facility. Alternatively, if this referral is for overseas medical care in the US, the referral will be sent to our overseas case coordinators, MMSI **, for all US-based care. For all referrals to Jamaica, the CINICO MCMU will send the referral through to our network in Jamaica for coordination assistance.

 

**MMSI, CINICO Overseas Care Coordinators, may be reached at the following: 1 (855) 733 0103, or cinico@mayo.edu.

 

Q: Can I go to a private doctor?
A:

Not unless a Chief Medical Officer (CMO) approved referral is obtained.

Q: Do I require pre-approval for certain medical procedures?
A:

All medical services must be provided at HSA or a CMO approved referral is required for service to be covered at another facility.

Q: What is a referral?
A:

A referral is a written document generated any time your Cayman Islands Health Services Authority (CIHSA) primary care physician requests you to be seen by anothery physician.

    a.    There are two types of referrals:
           i.    Referral within the CIHSA
           ii.   Referral for services outside the CIHSA

    b.    A referral within the CIHSA is made by your physician at the CIHSA to another physician within the CIHSA. No Chief Medical Officer (CMO) approval is required for internal CIHSA referrals.

    c.    A referral for servcies outside of the CIHSA will occur if you physician feels it necessary for you to receive medical service which are unavailable within the CIHSA. As such, he/she will complete a referral form. You may then take this referral from to the CIHSA Referral Office, located on the second floor of the CIHSA main building. At the Referral Office, you will be asked to fill in your own details on the referral form (Name, date of birth, CINICO ID#**, and contact details. Once this is completed, the Referral Office will commence inputting this into their system for CMO approval.

 

**Your CINICO ID# is located on the front of your CINICO card. You should use this number, along with your name and date of birth, to identify yourself when communicating with CINICO.

 

Q: Am I eligible for SHIC Coverage?
A:

CINICO currently provides Health Care coverage to all residents of the Cayman Islands through the provision of the Standard Health Insurance Contract (SHIC) via two (2) catagories of Plans:

 

Affordable Plan Participation

Single, Couple and Family Coverage is available to any Legal Resident of the Cayman Islands who is under 60 years of age. In addition, Legal Resident Spouses, Children under 18 years of age & Dependent Offspring* may also be enroll in this plan.

 

* Dependent Offspring: Children of Eighteen (18) years of age or older, but under Thirty (30) years of age, who for medical or physical reasons is dependent on the Insured member for shelter or care and/or financial reasons. 

 

Silver Plan Participation

Participation is only available to individual residents of the Cayman Islands who are aged 60 or older.
Children & Dependent Offspring may not enroll in this plan.

Q: Am I eligible for Civil Servants and Pensioners Coverage?
A:

The Civil Servants and Pensioners plan is available to the employees of the Cayman Islands Government and its Entities.

- A new employee must enroll for coverage by signing an employment agreement with the Cayman Islands Government

- A newborn child of an insured parent will be automatically enrolled for 30 days from birth. Charges incurred for benefits and nursery care will be applied against the newborn child's plan. However:

  • If proper documentation is not received within the 30 days, coverage for the newborn will cease on the 31st day. At that point, the covered parent will be responsible for all costs incurred by the newborn.
  • Coverage will be reinstated following receipt of the birth certificate but retroactive reinstatement for dependent coverage must occur within 90 days.

- Pensioner eligibility for coverage will be dependent on that individual's employment agreement upon retirement.

Q: Am I eligible for Seafarers and Veterans coverage?
A:

Seamans and Veterans: As defined under the Health Insurance (Amendment) Law, 2003, are those who reside in the Cayman Islands and who:-

1.     Is a member of either the Veterans' and Seamens' Society of Cayman Brac and Little Cayman or of the Cayman Islands Seafarer's Association or a member of the Cayman Islands Veterans' Association; and

2.     First went to sea before January 1, 1985 or served in the armed forces before 1973.

3.     Was a Caymanian (as defined under the immigration Law (2003 revision) during the period of time when he was at sea, or served in the armed forces.

If you qualify in all of these categories AND are resident in the Cayman Islands, you will be eligible for coverage with CINICO.

Q: What is my employer’s responsibility for paying my premium?
A:

Your employer's minimum responsibilty is 50% of the Standard Health Insurance Contract (SHIC). Presently the base premium, as defined by the Health Insurance Law (2013), is CI$167.00. Therefore your employer is responsible for a minimum of CI$83.50.

Q: What banks can I do direct debit with?
A:

We only accept for Cayman National Bank (CNB), Royal Bank of Canada (RBC), ScotiaBank, Bank of Butterfield and Fidelity.

Q: What happens if my payments are not made within the time frame?
A:

Failure to make your premium payments within the 30 day time frame, will result in your policy being terminated for non-payment.

Q: Can I pay by credit card?
A:

No. CINICO does not accept credit card payments as yet.

Q: How can I apply for Direct Debit.
A:

Forms can be picked up at CINICO’s office or printed off the website.

Q: What are the penalties for NSF (Not Sufficient Funds) cheques?
A:

There is a charge for any NSF cheque.  Your premium payment made on that Cheque will be null and void and your policy can be at risk for termination.

Q: How can I pay my premiums?
A:

a.  At Banks, premiums can be paid online at: Bank of Butterfield and Cayman National Bank. CNB also offers at the counter service. Royal Bank (Cayman) Limited. RBC also offers ATM deposit at the counter service. 

b.  At CINICO’s office: Direct Debit forms can be filled out and submitted to CINICO for submission to the following banks: Bank of Butterfield, Cayman National Bank, Royal Bank (Cayman) Limited, Fidelity Bank, and Scotiabank. Note: CINICO is responsible for submitting your Direct Debit payment request to the banks on the 1st of each month.

Q: When are my premiums due?
A:

Premiums are due on the first (or first working day) of each month.

Q: Do I receive any invoices?
A:

No invoices are sent out.  All members are advised upon enrollment that premiums are due on the 1st of each month.

Q: Where else can I go to pay my policy?
A:

You can pay it at the counter at RBC & CNB. 

Q: What banks can I use for online banking?
A:

You can bank online with Butterfield, RBC & CNB.

Q: Where can I pay my premiums?
A:

At any participating bank, through online banking, direct debit or at the CINICO office.

Q: How do I renew my Home Health Care (HHC)?
A:

As all approved HHC Applications are valid for a maximum period of 180 days, all members receiving HHC are required to submit a HHC Renewal Application a minimum of thirty (30) days before the expiration of the currently approved HHC benefit.

 

NOTE: For all prior approved HHC, CINICO will automatically cease the provision of benefit coverage unless a renewal application form is submitted 30 days before the expiration of the currently approved application.

 

In order to renew your previously approved Home Health Care Coverage, an eligible member who is employing a Caregiver directly must provide the following documentation a minimum of thirty (30) days before the expiration of the currently approved HHC benefit:

 

  1. A member must complete a ‘CINICO HHC Application & Renewal Form’
  2. A member must obtain a Physician Completed ‘HHC Care Level & Plan Form’ (Level  1, 2 or 3)
  3. A member must also obtain a Physician HHC Plan/Letter from the CIHSA Physician with a current CMO Stamp

 

NOTE: If there is a change in Caregiver, the following information must also be supplied with the HHC Renewal Form as listed in Items 4 thru 8 below:

 

  1. A member must provide proof of the Caregiver's Professional Qualifications* (Level 1 only) & Proof of CPR & First Aid training (Level 1, 2 or 3)
  2. Employment Agreement with wage or salary between Member/Employer and Caregiver
  3. Work Permit approval letter (If expatriate)
  4. Proof of Medical Insurance for Caregiver
  5. Proof of Pension for Caregiver (If applicable)

 

*Proof of the Caregiver's Professional Qualifications, CPR and First Aid Training must  be provided to CINICO by the Member or Home Health Care Vendor, whomever is providing the employment.

 

In order to renew your previously approved Home Health Care Coverage, an eligible member who is utilizing a Home Health Care Vendor must provide the following documentation a minimum of thirty (30) days before the expiration of the currently approved HHC benefit:

 

  1. A member must complete a ‘CINICO HHC Application & Renewal Form’
  2. A member must obtain a Physician Completed ‘HHC Care Level & Plan Form’ (Level  1, 2 or 3)
  3. A member must also obtain a Physician HHC Plan/Letter from the CIHSA Physician with a current CMO Stamp

 

NOTE: If there is a change in Home Health Care Vendor or the Caregiver, the following information must also be supplied with the HHC Renewal Form as listed in Items 4, A thru D below:

 

  1. A member must provide proof of the Caregiver's Professional Qualifications* (Level 1 only) & Proof of CPR & First Aid training (Level 1, 2 or 3)

   A. Proof of current T&B Licence of the HHC Vendor

   B. HHC Vendor must present proof of employee qualifications (See #4)

   C. All HHC Vendor Invoices must be signed by CINICO policy holder or designated guardian

   D. All contracts between CINICO policy holder & HHC Vendor must also be presented.

 

 Only completed applications will be presented to the CINICO Risk and Appeals Committee for approval.

Q: What are the levels of the Home Health Care (HHC) Benefit?
A:

The HHC guidelines contain three levels of HHC, differentiated by the acuity of care and medical needs (Level 3 being the lowest and Level 1 being the highest level):

 

  • Level 3: Care Assistant - No formal training or qualification, but have experience with caring for an individual in the home setting with supporting references of such. Must complete a basic Home Nursing course, and work under the supervision of a Registered or Licensed Practical Nurse for a minimum period of 6 weeks plus hold an up to date CPR and First Aid certification.

    Care provider must be able to provide basic care and supervision, assist with light housework and meal preparation. However, they must know how to respond in an emergency until a medical team or ambulance arrives. Note: If they are required only when non-medical care is needed, i.e. mainly provide companionship and supervision, this care would be deemed convalescence, which is not a covered benefit.

 

  • Level 2: Nursing Assistants - must have a background in health care, evidence of some formal training although it is not essential to hold a professional qualification. NVQ training level 1 or equivalent. CPR and First Aid essential.

    Care provider is capable of delivering basic nursing care, such as turning, changing, bathing and feeding a patient. They are permitted to take and record BP and other vital signs and recognising changes outside the normal range. They are also capable of observing changes in a patient’s condition and alerting medical assistance and works closely with the Physician. Written reports of care are maintained. (Also Level 3 care)

 

  • Level 1: Registered Nurses and Licensed Practical Nurses must hold and maintain a valid license to practice issued by the Cayman Islands Health Practice Commission. Plus up to date CPR certification.

    Care required in a home setting for patients recovering post-operatively to enable them to leave the hospital setting sooner, or for patients receiving treatment such as chemotherapy, pain management. Caregiver is expected to administer prescribed drugs in the home setting and perform dressing and wound management in association with the GP or Physician prescribed plan structure. (Also Level 2 & 3 care).

 

These care levels are determined by the referring physician and reviewed for appropriateness by the Risk and Appeals Commitee.

 

The maximum monetary limit* of each level is as follows:

  • Level 3 = KYD $1,200 per month
  • Level 2 = KYD $2,000 per month
  • Level 1 = KYD $3,000 per month

 

*These monetary limits are established by the Risk and Appeals Committee and are subject to periodic review and change without prior notice.

 

All HHC contain some level of convalescence care. As convalescent care is not a covered benefit, the Risk and Appeals Committee will examine the percentage of time utilized, of a particular HHC application, for the health based care versus the time spent providing convalescent care. Based on this analysis, the R&A Committee will authorize a percentage of the maximum amount as defined per each level and authorize accordingly.

Eg. A level 3 applicant, may apply for $1,200 but only receive, $800 based on the quantity of true health based care as opposed to the amount of convalescence care.

Q: Who is eligible for the Home Health Care Benefit?
A:

The HHC benefit is limited to members covered under the  following plans:

  • Civil Servants & Pensioners (SAGC's) Group 30100
  • Seafarers & Veterans Group 30101
  • Indigents Group 30102

NOTE: SHIC - Affordable and Silver Plans - 31304 do not contain the Home Health Care Benefit.

Q: What is Home Health Care?
A:

Home Health Care (HHC) is a covered benefit for members who have a medical condition(s) that require some level of medical care assistance at home following a period of hospitalization and/or due to their medical condition(s) and health needs. HHC should be in lieu of hospitalization or for the prevention of hospitalization. The HHC benefit includes part-time or intermittent nursing care by or under the supervision of a Registered Nurse (R.N.); part-time or intermitted home health aide servies provided through a Home Health Care Agency (this does not include general housekeeping services); physical, occupational and speech therapy services, medical supplies and laboratory services by or on behalf of the Hospital.

 

The HHC benefit is limited to members covered under the following plans:

  • Civil Servants & Pensioners (SAGC's) Group 30100
  • Seafarers & Veterans Group 30101
  • Indigents Group 30102

NOTE: SHIC - Affordable and Silver Plans - 31304 do not contain the Home Health Care Benefit.

 

All Home Health Care Plans (HHCP) must meet these four (4) tests:

  1. The HHCP must be a formal written plan made by the patient's attending Physician and approved by the Chief Medical Officer (CMO) and must be reviewed at least every 180 Days
  2. The HHCP must state the diagnosis (including relevant medical information, special requirements etc.)
  3. The HHCP must certify that the HHC is in place of Hospital confinement
  4. The HHCP must specify the type and extent of HHC required for the treatment of the patient.

 

All HHC Applications are reviewed and authorized by the CINICO Risk & Appeals (R&A) Committee. Please note, all HHC contain some quantity of convalescent care. As convalescent care is not a covered benefit, the R&A Committee will examine the application and the specific percentage of time utilized exclusively for medical care versus convalescent care. Based on this analysis, the R&A Committee reserves the right to vary the requested reimbursement and/or period, to an amount less than the defined maximum per each level.

 

All approved HHC Applications are valid for a maximum period of 180 days, after which CINICO will automatically cease the provision of benefit coverage unless a renewal application form is submitted 30 days before the expiration of the currently approved application (see FAQ "How do I renew my Home Health Care?")

Q: How can I get Home Health Care (HHC)?
A:

The HHC benefit is limited to members covered under the following plans:

  • Civil Servants & Pensioners (SAGC's) Group 30100
  • Seafarers & Veterans Group 30101
  • Indigents Group 30102

NOTE: SHIC - Affordable and Silver Plans - 31304 do not contain the Home Health Care Benefit.

 

Please refer to the CINICO HHC Checklist and HHC Application Form.

 

In order to obtain Home Health Care Coverage, an eligible member must complete the following:

  1. A member must complete a ‘CINICO HHC Application & Renewal Form’
  2. A member must obtain a Physician Completed ‘HHC Care Level & Plan Form’ (Level  1, 2 or 3)

  3. A member must also obtain a Physician HHC Plan/Letter from the CIHSA Physician with a current CMO Stamp

  4. A member must provide proof of the Caregiver's Professional Qualifications* (Level 1 only) & Proof of CPR & First Aid training (Level  1, 2 or 3)

 

*Proof of the Caregiver's Professional Qualifications, CPR and First Aid Training must  be provided to CINICO by the Member or Home Health Care Vendor, whomever is providing the employment.

 

If a member is employing a Caregiver directly, the following must also be submitted:

  1. Employment Agreement with wage or salary between Member/Employer and Caregiver
  2. Work Permit approval letter (If expatriate)
  3. Proof of Medical Insurance for Caregiver
  4. Proof of Pension for Caregiver (If applicable)

 

If a member is utilizing the services of a Home Health Care Vendor, the following must also be submitted:

   A. Proof of current T&B Licence of the HHC Vendor

   B. HHC Vendor must present proof of employee qualifications (See #4)

   C. All HHC Vendor Invoices must be signed by CINICO policy holder or designated guardian

   D. All contracts between CINICO policy holder & HHC Vendor must also be presented.

 

 Only completed applications will be presented to the CINICO Risk and Appeals Committee for approval.

 

As  per the New HHC application and guidelines, the three levels of Home Health Care has been defined: The maximum limits of each level is as follows:

  • Level 3 = $1,200 per month
  • Level 2 = $2,000 per month
  • Level 1 = $3,000 per month

 

All HHC contain some level of convalescence care. As convalescent care is not a covered benefit, the Risk and Appeals Committee will examine the percentage of time utilized, of a particular HHC application, for the health based care versus the time spent providing convalescent care. Based on this analysis, the R&A Committee will authorize a percentage of the maximum amount as defined per each level and authorize accordingly.

  • Eg. A level 3 applicant, may apply for $1,200 but only receive, $800 based on the quantity of true health based care as opposed to the amount of convalescence care.
Q: What is the local Provider claims process?
A:

CINICO utilizes a number of Non-CIHSA Physicians and Facilities for the treatment of our members (see Referrals Process).

 

Non-CIHSA Physicians and Facilities are required to obtain a vendor identification number from CINICO. Once a vendor ID number is granted, these providers can submit their claim on a CINICO Claim Form to CINICO for processing via the dedicated email intake box: providerclaims@cinico.ky 

 

All claims submitted to the providerclaims@cinico.ky inbox must abide by the following rules:

  • The subject line of the email must contain the "Physician or Facility or Practice Name / CINICO Provider ID# / Member Name / CINICO Member ID# / Date of Service"

For example:

                "Dr. Smith or XYZ Medical or XYZ Associates / 123456 / John Smith / 999-99-9999 / Jan 31 2014"

 

In addition, all CINICO Claim Forms must contain a signature of the Member that has been referred to the non-CIHSA Provider. Furthermore, the submitted CINICO Claim Form must include a copy of the referral authorized by the Chief Medical Officer (CMO).

 

CINICO uses a Third Party Administrator (TPA) in the United States to adjudicate all claims and process reimbursements.

 

Once a valid claim is received by CINICO, we submit this document for processing to our TPA. Our TPA in turn validates the eligibility of the member, their plan and benefit coverage. 

 

Provided all elements of the claim and member eligibility are compliant, the claim is adjudicated, the members accumulators are adjusted, and a cheque is created. These cheques are then couriered to the CINICO Office in Grand Cayman for final distribution.

 

Under the Health Insurance Law (Regulations) of 2013, all Class A Health Insurers have thirty (30) days from the receipt of a valid claim to issue payment or denial of the claim to the member.

 

Since September 1st, 2014, we are presently averaging nineteen (19) days for a claim reimbursement turn around.

Q: Is ground transportation covered for overseas referrals?
A:

CINICO does not cover any type of ground transportation on any plan.

Q: What is the maximum accommodation expense amount CINICO will cover?
A:

CINICO covers up to USD $120.00 per day plus room tax* for overseas medical referrals at a licenced lodging facility.

 

Overseas is defined as outside of the territorial region of the Cayman Islands.

 

*SHIC - Affordable and Silver 31304 - Plan does not include accommodation or commercial air transport benefits.

Q: How do I submit a claim for reimbursement from my overseas medical appointment?
A:

Eligible Reimbursement* Include: Hotel Accommodations, Prescribed Medications**, Prescribed Durable Medical Equipment (DME’s).

 
*Eligible reimbursement of approved expenses is subject to member eligibility and benefits based on the plan to which you have subscribed.
 
**Overseas Outpatient Prescribed Medications for Plan 30101 Seafarers and Veterans is not covered. SHIC – Affordable and Silver Plans 31304 – are subject to their Outpatient benefit.
 

A:Once the expenses you are seeking reimbursement for are valid in accordance with your plan, you are then required to:

 

Step 1: Complete a claim form
Step 2: Submit this with your invoices and proof of payment to either CINICO Office:
 
  • Grand Cayman Office located at #3 Cayman Centre, Airport Road or
  • Cayman Brac Office located at #143 Stake Bay, Cayman Brac.

 

Our Office hours are 9:00am to 4:00pm. Your claim will be processed and your reimbursement cheque will be mailed to the address listed on your current eligibilty file.

 

Each CINICO member has a designated Client Service Manager (CSM) who is responsible for all policy, eligibilty and premium questions. The Medical Case Management Unit (MCMU) is responsible for assisting members with any queries regarding Medical Referrals, both local and overseas. Please call the CINICO Grand Cayman main line at (345) 949 8101 or CINICO Cayman Brac (345) 948 8101 for further information.
Q: What is the turn around time for reimbursement claim?
A:

CINICO uses a Third Party Administrator (TPA) in the United States to adjudicate all claims and process reimbursements.

 

Once a valid claim is received by CINICO, we submit this document for processing to our TPA. Our TPA in turn validates the eligibility of the member, their plan and benefit coverage. 

 

Provided all elements of the claim and member eligibility are compliant, the claim is adjudicated, the members accumulators are adjusted, and a cheque is created. These cheques are then couriered to the CINICO Office in Grand Cayman for final distribution.

 

Under the Health Insurance Law (Regulations) of 2013, all Class A Health Insurers have thirty (30) days from the receipt of a valid claim to issue payment or denial of the claim to the member.

 

Since September 1st, 2014, we are presently averaging nineteen (19) days for a claim reimbursement turn around.

Q: How do I complete a CINICO claim form?
A:

For a valid claim submission you must;

1. Fill out a claim form & sign
2. Submit with the completed claim form documentation an itemized bill from the provider that indicates the services and charges that were issued and paid listed on the claim form along with a matching payment receipt
3. Submit with the completed claim form documentation a Chief Medical Officer Referral or other authorized document indicating authorization for the services provided


For a valid claim form submission for reimbursement you must complete the following sections on the claim form:

Section 1a:  Insured I.D. Number (CINICO Member ID #) 
Section 2:   Patient Name (the person who received the service)
Section 3:   Patient Date of Birth
Section 4:   Insured's Name (if different than patient name)
Section 5:   Patient's address
Section 6:   Patient's relationship to insured
Section 7:   Insured's address (if different than patient address)
Section 8:   Patient status
Section 11:  Insured's Group or FECA number (if different than patient address)
Section:12:  Patient or Authorized Person signature to authorize releasing medical records and reimburse insured member or party who accepts assignment for services provided on claim form
Section 13:  Patient or Authorized Person signature to authorize reimbursement to medical provider or supplier for services provided on claim form   
Section 24A: Fill in the dates of when the services were provided that is being claimed for reimbursement
Section 24F: Fill in the total amount paid for each date of service
Section 28:  Total the amount paid in section 24F
Section 30:  Total the amount paid you are claiming to be reimbursed 
 

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