Glossary
Health Coverage
Benefit Period:
The period of time Plan is in force and benefits for Covered Services may be available. Charges for Covered Services are considered incurred on the date they are provided.Co-payment:
The dollar amount of Covered Services (specified in the Schedule of Benefits) that must be incurred and paid by a Member before benefits are payable for all or part of the remaining Covered Services.Coinsurance:
The share of the cost of Covered Services by Health Plan and You, after Your Deductible has been satisfied.Coverage:
The benefits available to You under Your health policy.Covered Service:
A service or supply for which benefits are available.Deductible:
The dollar amount You must incur and pay for Covered Services during a Benefit Period before We provide benefits.Explanation of Benefits (EOB):
The form provided to the Subscriber after a claim has been filed notifying the Subscriber which services were covered and which, if any, were not.Family Deductible:
The maximum dollar amount of Covered Services stated in the Schedule of Benefits that must be incurred and paid by a Subscriber before benefits are payable for all or part of the remaining Covered Services.Family Out-of-Pocket Maximum:
The maximum dollar amount stated in the Schedule of Benefits for which a Subscriber is responsible to pay for Covered Services during a Benefit Period.Health Plan:
An entity that provides, offers or arranges for Coverage of designated health services needed by plan members for a fixed, prepaid Premium.Individual Coverage:
Coverage for the Subscriber only.Maximum Allowable Charge (MAC):
The amount the Health Plan has determined to be the maximum amount payable for a Covered Service. Maximum Allowable Charge will be based upon Health Plan, or its affiliate or third party vendor's, contract with a Network Provider or the amount payable based on Health Plan, or its affiliate or third party vendor's, fee schedule for the Covered Services when rendered by Out-of-Network Providers.
Maximum Benefit:
The total dollar amount of benefits available under the Contract during the Benefit Period, as stated in the Schedule of Benefits.Member:
Any person enrolled under the Coverage as a Subscriber or a dependent.Network Provider:
A Provider who has contracted with Health Plan, its affiliate, or a third party vendor to provide Covered Services to Members at specified rates.Out-of-Network Provider:
A Provider who has not contracted with Health Plan, its affiliate, or a third party vendor to provide Covered Services to Members at specified rates.Out-of-Pocket Maximum:
The maximum dollar amount You could incur and pay for Covered Services during a Benefit Period, including Deductible and Coinsurance.Pre-Existing Condition:
An illness, injury, pregnancy or any other medical condition which existed at any time preceding the Effective Date of Coverage under the contract for which:- Medical advice or treatment was recommended by, or received from, a provider of health care services; or
- Symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.
Pre-Existing Condition Waiting Period:
The specified period beginning with the policy Effective Date. This is the period during which no benefits are payable for care, treatment, or services for Pre-Existing Conditions.Premium:
The amount paid by or on behalf of the Subscriber each billing cycle for Coverage provided under the terms of the Contract.Subscriber:
A Member who has satisfied the eligibility requirements and enrolled for Coverage under the Plan.Third Party Administrator (TPA):
An organization that processes insurance claims for a separate entity.