Medical Insurance Terminology Business Staff What is Insurance

Medical Insurance Terminology Business Staff

What is Insurance? Financial health protection for health risk Purchased by an individual or employee Covers an individual and his/her dependents

Who is a Guarantor? The person responsible for payment If a patient is under 18, disabled or an adult with a legal guardian, they must have a guarantor.

Who is a Subscriber? The insurance policyholder.

Who/What is a dependent? Someone that can be covered under an insurance plan (example - spouse, children, nieces, nephews, grandchildren)

What is a Copay? The set amount a patient pays at an office visit.

What is a Deductible? A set amount the patient is responsible for before insurance will pay.

What is Co - insurance? The percentage of payment the patient must pay after the insurance has paid their portion.

Out of Pocket Expense? Amount that isn’t reimbursed by insurance. This includes deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

ICD-10 and CPT ICD-10 (International Classification of Disease Vol. 10): Diagnosis code that tells what the patient has. CPT (Current Procedural Terminology): Procedure code that tells what is being done to the patient.

What does EOB stand for? Explanation of Benefits: A statement sent by a health insurance that explains what medical treatments or services were paid for or left for patient responsibility.

Primary / Secondary Insurance When a patient has more than one insurance plan, they will have a primary and a secondary insurance.

Primary/Secondary: Birthday Rule If a patient (usually a child) is covered under both insurance plans from their parent, the “Birthday Rule” determines which insurance is primary. Birthday Rule: The insurance from the parent whose birthday falls first in the calendar year is the primary insurance. Exceptions: COBRA vs regular health insurance: If your spouse has COBRA insurance through a prior employer and you have a health insurance plan through your current employer, your plan is the primary.

Primary/Secondary Birthday Rule Exceptions Legally separated or divorced and not remarried: the custodial parent’s plan is the primary and the noncustodial parent’s plan is secondary. Divorced and remarried: The custodial parent’s plan is the primary, the stepparent’s plan is secondary. If costs remain, the noncustodial parent’s plan pays last. The patients policy is primary if he/she has insurance where they are the policyholder and also covered under their spouse

Medicare is secondary if the patient is employed and has insurance through their employer Medicare is secondary if a patient is covered under a spouses insurance who is employed A patient would never have a Medicare Replacement Plan and Medicare at the same time. This rule also applies for Medicaid and Medicaid Replacement Plans.

Medicare and VA There will be situations where a patient has both Medicare and VA Insurance (not to be confused with Champ VA). The patient must choose which insurance they want the visit filed to. An authorization must be presented at the time of visit If the patient chooses the VA Insurance.

In-Network vs. Out of Network If ADC has a contract with an insurance, we are considered In-Network. As a general rule, PPO, POS, and HMO plans make use of provider networks. Indemnity plans typically do not.

What does Assignment mean? Assignment means ADC can file claims to the insurance company.

What does Non. Assignment mean? ADC does not have a contract with an insurance company. Non-Assignment = ADC will not file a claim to the patient’s insurance. **All Indemnity insurances without a network should be loaded as “Non Contracted Assigned” in order for a claim to be filed to the insurance.

3 Categories of Insurance Indemnity Managed Care Government Based

Indemnity Insurance Group or Individual Deductible % based plan (90/10, 80/20) Any Lab Any Doctor Any Hospital

3 Types of Government Based Plans Medicare Medicaid Tricare (Not accepted as primary insurance at ADC)

Medicare Part A (Hospital) • 62 years old to qualify • $1, 216 deductible (per benefit period) Medicare Part B (Medical) • 65 years old to qualify • $166 deductible • 80/20 plan (after patient has paid deductible) • Any Doctor • Any Lab

Medicare Advantage/Replacement Plans ADC is not contracted with Medicare Advantage/Replacement plans, but will still see established patients only if it is a PPO plan. Patients with HMO Medicare Advantage/Replacement plans (except Humana) will have to seek care elsewhere. The only Medicare Advantage plans ADC is contracted with are Humana Medicare Advantage (PPO, PFFS, Healthselect ERS, and HMO).

Medicaid Some ADC departments will see patients with certain types of Medicaid. 30 day re-qualification Pregnant mothers, Terminally Ill, Renal Failure, Disabled

Primary Care Physicians (PCP) Family Practice Internal Medicine Pediatrics OB/GYN* *ADC OB/GYN providers should not be selected as PCP’s unless the provider has agreed to be the patient’s PCP.

Managed Care These are the people that manage your care. Physicians Insurance Hospitals Labs All managed care plans have a Network and rules to follow.

3 Products of Managed Care Plans PPO-Preferred HMO-Health Provider Organization Maintenance Organization EPO/Po. S -Enhanced or Point of Service Provider Organization

PPO - Preferred Provider Organization Any Physician in the NETWORK Set co-pay Assigned- If we are CONTRACTED Deductible Stay in Network w/Hospital and Lab Out of the Network-Insurance pays Reduced Rates

HMO - Health Maintenance Organization PCP-Primary Care Physician Referral to see a Specialist Set co-pay Assigned- If we are CONTRACTED Deductible Out of Network- Insurance pays nothing (0. 00)

Enhanced Provider Organization or Point of Service (EPO or Po. S) May require a PCP-Primary Care Physician May require a referral to see a Specialist Set co-pay Assigned- If we are CONTRACTED Deductible Out of Network-Some plans will pay Reduced Rates

Workers Compensation ADC does not accept patients with Workers Compensation. (Ophthalmology will still take some patients)

What is Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers “onestop shopping” to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace began in October 2013.

Marketplace Plans Sendero Ideal. Care ADC accepts the Sendero Ideal. Care plan offered through the marketplace. *This is not a Medicaid plan* Sendero CHIP and Star products are excluded from this contract, as well as Pediatric services

Marketplace Plans Aetna plans ADC does not accept any Aetna plan offered on the Marketplace. Aetna plans offered on the Marketplace will have “QHP” on the insurance card. Cigna plans ADC does not accept any Cigna plan offered on the Marketplace. Cigna plans offered on the Marketplace are all under the Local Plus Network.

Marketplace Plans United Healthcare ADC does not accept the Compass EPO plan offered on the marketplace. The cards will have the United Healthcare logo and the Compass product name with the member’s PCP Humana ADC does not accept any Humana plan offered on the Marketplace (National POS and HMOX) ADC does not accept any other plans offered on the Marketplace.