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The percentage paid by a PPO member to the in-network provider after the deductible has been met. Copay Set fees paid by the member to the provider at the time services are rendered.
A set amount of covered charges, which must be paid by a PPO member in full each calendar year prior to the insurance company paying their percentage of the bill. Dependent The legal spouse or child of the subscriber.
The guidelines used to determine who qualifies for coverage under a health plan. Emergency Service Medically necessary inpatient or outpatient covered services that may not be delayed and must be or appear to be needed immediately to prevent death or a serious impairment of the member’s health. Exclusions Services not covered under the member’s contract even if medically necessary.
Fee paid to the provider for each separate service rendered. Formal Grievance Complaint or dispute registered to the plan in writing. Formulary A list of drugs or classes of drugs preferred by a health care plan for use by its enrollees.
A drug that is a chemical and therapeutic equivalent of a brand-name drug for which the patent has expired. Generic drugs are usually less expensive than the equivalent brand-name drugs. Grievance A process or procedure in which the plan addresses a member’s dispute against the health plan.
The Florida Healthy Kids Corporation was established in 1990 by the Florida Legislature as a public-private initiative to improve access to comprehensive health insurance for the state’s uninsured children. Healthy Kids covers children age 5-18 who are uninsured and not eligible for Medicaid or Children’sMedical Services. Health Maintenance Organization (HMO): An organization that contracts with selected health care providers to offer its members comprehensive preventive, hospital, and medical services for a pre-paid fee. In most cases, members' care is coordinated by a primary care physician (PCP).
A government program that provides medical assistance for certain low-income individuals and families. Medicare A health insurance program for people over age 65, the disabled, and people with end-stage renal disease who require dialysis or transplantation. Member The enrolled person who has the right to the plan benefits described in the Subscriber Certificate or Benefit Description. A member may be the subscriber or his or her enrolled spouse (or former spouse, if applicable) or an enrolled dependent child.
Medications not listed on a plan's formulary, and therefore not covered by the plan.
A set time when eligible persons may elect to enroll in a health plan. Out-of-Area Benefits Coverage provided for services obtained outside of the network service area.
Medicare members who have hospitalization coverage. Part B of Medicare Medicare members who have medical coverage. Participating Providers Health care providers under contract with a health care company. Point-of-Service (POS) Plan A health benefit plan that provides more comprehensive coverage for health care services furnished by selected in-network providers and a lesser level of coverage for health care services by out-of-network providers. Preferred Provider Organization (PPO) Plan A network-based health plan that allows members to see any provider, but provides a higher benefit level when members use network providers. Primary Care Physician (PCP) Doctor chosen to provide basic medical care and to coordinate the member’s total medical needs.
The counties that the insurance plan participates in and has contracted providers and hospitals available to members. Specialists Providers who provide specific types of health care services that treat specific areas of the body or types of disease, like a Gynecologist, pediatrician, and neurologist. Subscriber An eligible person enrolled in a health plan.
The usual, reasonable, and customary charge determined by the plan.
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