For in-network doctors, this is the portion the participant pays for receiving services.
The amount of money an employee pays before their insurance plan starts paying.
Dependent Age Out (DAO)
A dependent who doesn't enroll in college by a certain age (usually 19) cannot continue on their parent(s)' benefits. Companies do allow college-age depend ents to be on plans while they are in school. Most companies do not allow dependents to be on plans after age 23 t o 25, dependent on the company.
Some companies will allow a dependent to be covered even if not in school if the dependent is disabled.
When a company pays one price per employee/family per month to have a benefit, they are fully insured.There is no further risk with high claims.
Health Maintenance Organization (HMO)
An HMO Plan requires an employee and their family to select a primary care physician (PCP). If they need to see a different doctor, the primary care physician must give a referral to see another doctor. Participants are usually allowed to change PCPs during a plan year; however, if they go out of network or visit a doctor without a referral, an HMO traditionally will not pay anything towards the bill.
Health Savings Account (HSA)
An HSA is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds may be used to pay for qualified medical expenses at any time without federal tax liability.
High Deductible Health Plan (HDHP)
This plan has a lower premium than PPO or HMO plans, but has a very high deductible. Participants in an HDHP are eligible to contribute to a Health Savings Account (HSA)
HIPAA is a legal requirement that regulates how organizations must handle Protected Health Information (PHI).
An "in-network" doctor has an agreement with an insurance carrier to provide services for a reduced price because they know they will be paid by the insurance carrier. The doctor's office will bill the carrier. In most plans, the participant will have to pay a co-payment for an office visit, an d/or there may be a deductible for services provided by a hospital.
Medical plans may cover hospital visits, doctor visits, x-rays, tests, etc. that are covered in the plan offered by the company. Carriers (Aetna, Cigna, and BCBS) offer a variety of plans that a company can choose from. The company can either choose a package that the carrier offers or change/select specific benefits to offer based on what the employer feels is appropriate.
If an employee elects to see a doctor who does not have an agreement with their insurance carrier, they will generally need to pay a deductible before the insurance company will pay. They have the freedom to be in or out of network, but they will pay more if they select a doctor who is out of network.
Preferred Provider Option (PPO)
A PPO Plan allows an employee to visit either in or out of network providers and still receive some benefits from the insurance company. To receive a better benefit, an employee will usually go "in network".
Self-insured companies usually have a carrier or TPA who does the administration, approves the claims, and then bills the company for the claims. The company pays a fee for administration, and pays for the entire cost of claims.
This medical plan is not used often anymore. Participants may see any provider they wish; there are no discounts or networks to follow. You generally pay a deductible – after that is met, the plan will pay a percentage.