Group Access cares
about our clients and their employees. We try to provide the
best exclusive services possible. We want our clients to have
easy access to their benefits and have the proper tools for
benefit compliance. To see some of the things we provide please
view our Demo.
view our Demonstration Click Here
Group Access would like to provide some useful
information to help you with the terminology of the insurance
Items available in this section
Useful Tips and Glossary
Useful tips and Terms:
Health insurance can be difficult to understand.
Group Access, Inc would like for you to get the most out of
your benefits. We have provided a few useful tips and a glossary
to help you have a better understanding of your benefits. For
more information on health, life and other types of insurance
go to these web sites. (www.iii.org or www.ahip.org)
As an insured you have rights and responsibilities
Rights – You have the right to…
… choose your own physician from the network
… accept or refuse medical treatment
… obtain information from your doctor to help in make
decision for your best care
… have your medical information is kept private
… voice your concerns or ask questions about your care
Responsibilities – You have the responsibility
… insure that the provider you are seeking treatment from
is in the network
… have your insurance card with you
… if you have concerns about a bill, call the insurance
company and or the provider
… acquire information to be able to decide what will be
your best medical care
you can expect:
Your primary care physician should verify that the doctor he
is referring you to is in the network but it is your responsibility
as well to insure that they are in the network.
Suggestion: When you call to make your appointment
ask them if they take your insurance and give them the information
on the card so they can verify it.
Emergency visits to the Hospital, When are they
covered? 55% of emergency room visits are not true emergencies.
The emergency room visit is only for life or limb threatening
situations; otherwise the insurance company will not pay. This
can be very costly to the insured.
Suggestion: Use good judgment when deciding
to go to the emergency room. Learn the symptoms that classify
an emergency. When in doubt call your PCP and describe your
symptoms. If it is after hours call the # on your card and the
insurance carrier will refer you to the closest after hour’s
facility in your area if it is not an emergency. (It will be
quicker than going the emergency room if you are just feeling
bad. The ER does not work on a first come first serve basis.)
Symptoms of an Emergency
1. Loss of consciousness
2. Signs of a Heart Attack
3. Signs of a Stroke
4. Severe shortness of Breath
5. A Severe Accident orBurn
6. Head Trauma
7. Severe or unusual bleeding that does not stop after 10
minutes of direct pressure
8. Sudden Severe Pain
9. Poisoning (If possible, call the poison control center.
Someone can give advise to help the problem until emergence
care can be given.)
10. Coughing or vomiting blood
11. A sudden severe reaction to insect bite or chemicals
12. Broken Bones
individual and group health insurance
Group insurance is offered to employers and groups (unions,
trade, and professional associations). The reason why group
insurance is much more affordable to buy is due to the fact
that insurance companies do not require evidence of insurability.
Risk is spread among members with both good and bad health conditions.
When trying to buy an individual health insurance policy, it
is usually required to undergo a medical exam that provides
the evidence of insurability. Insurance companies routinely
deny coverage to individuals because of risk factors, some of
which are not entirely based on the individual's medical history.
1. Remember with most dental insurance you only
have 2 cleanings per year that are covered at a 100%, if they
are 6 months and 1 day apart. So schedule your appointment(s)
2. Traditional dental insurance have a maximum benefit amount
they will pay out per year. Most are $1000 per year, but there
are a few that are higher. The max per year benefit is the most
that an insurance company will pay out per year for all dental
care work. Example: If you have more than $1000 a year in dental
work, the insurance company will pay up to that amount and the
overage is your expense.
3. Most dental plans have waiting period for particular procedures.
They are put into categories or Type Procedures (Type I, Type
II, Type III) Type I procedures usually have no waiting periods
while type II and III can have 0 months to 12 months depending
on your dental plan. This means that if you need any dental
work that falls into on of these categories you may have to
wait 12 months before the insurance company will pay any benefits
towards that procedure.
Disability can be more disastrous financially than death. If
you are disabled, you lose your earning power. You still have
living expenses and, often, huge expenses for medical care.
When purchasing disability insurance, ask:
· How is disability defined? Some policies consider you
disabled if you are unable to perform the duties of any job.
Better plans pay benefits if you are unable to do the usual
duties of your own occupation.
· When do benefits begin? Most plans have a waiting period
after an illness before payments begin.
· How long do benefits last? After the waiting period,
payments are usually available till you reach age 65, though
shorter or longer terms are also available.
· What dollar amount is promised? Can benefits be reduced
by Social Security disability and workers' compensation payments?
Are the benefits adjusted for inflation? Will the policy provider
continue making contributions to your pension plan so you have
retirement benefits when the disability coverage ends?
are the types of disability insurance?
There are two types of disability policies: Short-Term Disability
(STD) and Long-Term Disability (LTD):
1. Short-Term Disability policies (STD) have a
waiting period of 0 to 14 days with a maximum benefit period
of no longer than two years.
2. Long-Term Disability policies (LTD) have a waiting period
of several weeks to several months with a maximum benefit period
ranging from a few years to the rest of your life.Disability
policies have two different protection features that are important
1. Non-cancelable means the policy cannot be canceled by the
insurance company, except for nonpayment of premiums. This gives
you the right to renew the policy every year without an increase
in the premium or a reduction in benefits.
2. Guaranteed renewable gives you the right to renew the policy
with the same benefits and not have the policy canceled by the
company. However, your insurer has the right to increase your
premiums as long as it does so for all other policyholders in
the same rating class as you.
In addition to the traditional disability policies, there are
several options you should consider when purchasing a policy:
|Additional purchase options
- Your insurance company gives you the right to buy
additional insurance at a later time.
|Coordination of benefits
The amount of benefits you receive from your insurance
company is dependent on other benefits you receive because
of your disability. Your policy specifies a target amount
you will receive from all the policies combined, so this
policy will make up the difference not paid by other policies.
|Cost of living adjustment
The COLA increases your disability benefits over time
based on the increased cost of living measured by the
Consumer Price Index. You will pay a higher premium if
you select the COLA.
|Residual or partial disability
This provision allows you to return to work part-time,
collect part of your salary and receive a partial disability
payment if you are still partially disabled.
This provision requires the insurance company to refund
part of your premium if no claims are made for a specific
period of time declared in the policy
- Waiver of premium provision
This clause means that you do not have to pay premiums
on the policy after you’re disabled for 90 days.
Life Insurance Tips
should I buy life insurance?
Many financial experts consider life insurance to be an important
part of sound financial planning. Life insurance ca be beneficial
in the following situations:
1. Replace income for dependents
If people depend on your income, life insurance can replace
that income for them if you die. The most common situation is
parents with young children. It can also apply to couples; newly
married or seniors, in which the survivor would suffer financially
burden by the loss of income with the death of a partner. Insurance
to replace your income can be useful.
2. Pay final expenses
Life insurance can pay your funeral costs, debt, medical expenses
not covered by health insurance, probate and other estate costs.
3. Create an inheritance for your
You can create an inheritance by buying a life insurance policy
and naming them as beneficiaries.
4. Pay federal “death”
taxes and state “death” taxes
Life insurance benefits can pay estate taxes so that your heirs
will not have to liquidate other assets or take a smaller inheritance.
Changes in the federal “death” tax rules between
now and January 1, 2011 will likely lessen the impact of this
tax on some people, but some states are offsetting those federal
decreases with increases in their state-level “death”
5. Create a source of savings
Some types of life insurance create a cash value that, if not
paid out as a death benefit, can be borrowed or withdrawn on
the owner’s request. Since most people make paying their
life insurance policy premiums a high priority, buying a cash-value
type policy can create a kind of “forced” savings
plan. Furthermore, the interest credited is tax deferred (and
tax exempt if the money is paid as a death claim).
How much life insurance
do I need?
If you have no dependents and have enough money to pay your
final expenses, you don’t need any life insurance; however,
if you want to create an inheritance or make a charitable contribution,
you should buy enough life insurance to achieve those goals.
If you have dependent children, you should buy
enough life insurance to be able to combine with other sources
of income, if applicable, that would equal the income you provided
for your family.
important to name beneficiaries.
If you don’t name a beneficiary, the death benefit will
be paid to your estate. Before your surviving heirs can receive
any benefits it will need to go through the courts. That can
take some time if there are complications. While your loved
ones are waiting for the benefits to be paid, expenses are accumulating.
There are two types of beneficiaries “primary”
and “contingent” beneficiaries. You should identify
them as clearly as possible. Include their social security numbers
and the relationship to the insured. This will make it easier
for the life insurance company to find them, and it will reduce
the possibility of disputes regarding the death benefits. If
more than one beneficiary you should designate the amount of
benefit for each.
In the event that a beneficiary can’t be
found specify how the benefits are to be handled.
Organize and store
Life insurance records.
You do not want your beneficiaries to have trouble finding your
life insurance policy after you died. They are upset and confused
due to the circumstances. To prevent this, you should have copies
of your life insurance policies in two places or more. By doing
this it is less likely to lose them in a fire, a flood, or accidental
throw them a way and your beneficiaries will find them.
Keep one set of these records in your home, in a place where
others can find it. Remember to tell the people who will need
it where it is. Keep another set “off site”. Somewhere
outside of your home. Examples of “off-sire” are
a safe deposit box, with a professional or a trusted relative.Record
the date on your documents that the information was last updated.
This will let your beneficiaries know which is the more current.
I should keep.
For each individual life insurance
policy on your life, you should record the following
A B C
D E F
G H I
J K L M N
O P Q R
S T U
V W X Y Z
Accidental death and dismemberment
(AD&D) rider - A supplement that can be
added to many life insurance policies that provides an additional
cash benefit to the insured’s beneficiaries if an accident
causes either the death of the insured or causes the insured
to lose any two limbs or the sight in both eyes.
Annual out-of-pocket maximum
- A dollar amount set by the plan which puts a cap on the amount
of money the insured must pay out pocket for covered expenses
through the course of a calendar year.
Beneficiary - A person or party
that the owner of a life insurance policy names to receive the
policy benefit in the event of the insured's death.
- Prescription medications that are manufactured by the initial
developer of the medication.
Calendar-year deductible -The amount
of health or dental care expenses that the insured must pay
for covered eligible expenses before insurance payments.
Certificate of insurance
– A document that describes the type and length of coverage
provided by a group insurance policy that is given to each insured
by the group policyholder.
Claim - A request
for payment under the terms of an insurance policy; claims must
be filed with in 60 days of the date of service.
COBRA (Consolidated Omnibus
Budget Reconciliation Act) - COBRA requires organizations
with qualified health plans that have twenty or more employees
to offer the continuation of group health benefits (Medical,
Dental, Vision, and Medical Reimbursement Account) to employees
(and covered dependents) upon experiencing a "Qualifying
Event." (examples of “qualifying events” -
Termination of Employment , Reduction of Work Hours, Employee's
Death, Employee's Divorce (or legal separation in some states),
Medicare Entitlement, Change in "Dependent" Status)
Co-insurance - A
specified percentage of covered expenses an insured is required
to pay for all covered medical treatment remaining after the
policy's deductible has been met. (ex: 80/20 plan 80% is paid
by the carrier and 20% is paid by the insured)
Comprehensive major medical
policy - A health insurance policy that covers both major
medical expenses (i.e., hospitalization and surgeries) and basic
medical expense coverages.
Co-pay - (1) A payment
that many insurance plans require an insured to pay for certain
medical services such as a physician's office visit or an amount
that the insured must pay toward the cost of each prescription
under a prescription drug plan. For example, you may pay $20
for an office visit or $10 to fill a prescription and the health
plan covers the balance of the charges.
Deductible - A specified amount
of money to cover medical expenses that an insured must incur
before the insurer will make any benefit payments. (ex: A Hospital
stay; A $500 deducible must be paid to the hospital by the insured,
then co-insurance applies then the insurance carrier will pay
their portion of the cost.)
Dependent - A person
for whom the insured has some legal obligation or responsibilities.
For most plans, it is the insured's spouse and/or children.
Some plans also allow non-traditional spousal relationships
(significant other, life-partner, etc.) to be considered a dependent
with some additional certifying paperwork.
- Domestic partners are commonly defined as "two adults
who share an emotional, physical and financial relationship
similar to that of a married couple but who either choose not
to marry or cannot legally marry. They share a mutual obligation
of support for the basic necessities of life." Additionally,
some carriers may require that domestic partners own property
together to qualify.
Effective date - The specified
date of when the insurance policy is to begin.
Emergency care -
Most plans cover emergency care in a hospital emergency room
if it is an extremely urgent medical emergency (life or limb
threatening; the symptoms must be sudden, severe and require
immediate medical attention), even if the hospital you are taken
to is not in the plan's network. It is possible, however, that
after your condition has been stabilized, you would be transferred
to a participating plan hospital.
- The amount of premium the employer requires the employee to
pay for his or her health insurance.
- The time during which a new group member may first enroll
for group insurance coverage. Usually within 30 days of effective
Exclusions and limitations
- Conditions, situations and services not covered by the health
Fee schedule payment structure
- A fee structure used by insurers under which the insurance
company places caps or limits on the dollar amounts that it
will reimburse providers for covered medical procedures and
services, both in and out-of-network if applicable.
Formulary drugs -
A formulary drug is one that has been thoroughly reviewed by
a team of expert pharmacists and physicians; these drugs have
been identified as safe, effective and beneficial to members
for treating medical conditions. When deciding between drugs
which are equally safe and effective, the formulary team also
considers the relative costs of medications.
Fully insured plan
- A group insurance plan for which an insurance company bears
the responsibility of making all claim payments.
Generic (medications) – A
generic drug is a copy of a brand-name drug. The Food and Drug
Administration requires generic drug manufacturers to make all
generic drugs with the same active ingredients, dosage, safety,
strength, quality, and performance as the original medication.
When a new drug is put on the market, the pharmaceutical company
patents it under a brand name. The company has the exclusive
right to sell the drug under this name (usually 20 years), but
once its patent expires, other pharmaceutical companies can
sell the same drug under its generic name. Generic drugs are
typically cheaper than brand-name drugs.
group term life -
A life-insurance plan that provides employees with additional
coverage at economical group rates.
Health care provider -A doctor,
hospital, laboratory, nurse or anyone else who delivers medical
or health-related care.
- A type of insurance that provides financial protection against
the risk of excessive loss resulting from the insured person's
sickness, accidental injury or disability.
Health Insurance Portability
and Accountability Act of 1996 (HIPAA) - Under this federal
law (known as HIPAA), group health plans cannot deny coverage
based on an individual's health status. This law also gives
employees who change or lose their jobs better access to health
coverage, guarantees renew-ability and availability to certain
employees and limits exclusions for pre-existing conditions.
For example, under this law, group health plans must credit
any employee the amount of time that they spent on any health
plan prior to the new plan, which is known as "prior credible
coverage." A pre-existing condition will be covered without
a waiting period when an employee joins a new group plan if
the employee has been insured for the previous 12 months with
credible health insurance, with no lapse in coverage of 63 days
or more. This means that if an employee has been insured for
12 months or more, the employee will be able to go from one
job to another and his or her pre-existing coverage will remain
intact -- without additional waiting periods. However, if an
employee has a pre-existing condition and was not covered previously
for 12 months before joining a new plan, the longest the employee
will have to wait for their pre-existing coverage to be covered
is 12 months.
HMO (health maintenance
organization) - A health care system that provides comprehensive
health care for subscribing members in a particular geographical
area using managed care techniques. HMOs require that you only
utilize physicians within their network.
HSA (health savings account)
An HSA is a high deductible medical plan that includes a tax
deferred savings account. The money from the savings account
can be used to help meet the deductible or help pay early hospitalization/medical
Indemnity plan - A health insurance
plan that allows the insured to use any medical provider that
he or she chooses. This plan has no networks to utilize. There
are no co-pays or yearly max out of pockets with indemnity plans.
These plans potential out of pocket for the insured can be costly.
In-network – The insured using a doctor or facility
that is contracted to a network.
Insured - The person
who is covered under an insurance policy.
Lifetime maximum - The maximum
amount of money a plan will pay towards healthcare services
through-out the insured's lifetime.
Major medical insurance plan -
A type of traditional medical expense coverage that provides
substantial benefits for hospital surgical expenses and physicians'
Managed care - A
method of integrating the financing and delivery of health care
within a system that seeks to manage the cost, accessibility
and quality of care. HMO, POS, and PPO plans are all managed
Member - The person
who is covered under an insurance policy.
MSA – benefits - For the self-employed, Medical Savings
Accounts (MSA) allow you to build up a tax-free savings account
to pay for routine medical expenses. You build the account with
tax-free dollars, and they remain tax-free while your MSA is
active. Your MSA is used in conjunction with a high-deductible
insurance policy. With the high-deductible insurance plan, the
cost of an MSA can be kept competitively low. Tax-free dollars
and an affordable price save you money.
Network - A group of doctors, hospitals
and other health-care providers contracted with a health plan
to provide care at discounted rates.
- Non-formulary drugs are those that have not yet been reviewed
or have been denied formulary status, typically because they
offer no extra benefit over the drugs already on a plan's formulary
Out-of-network - Health care services
provided by a doctor or facility that is not contracted with
the health plans network.
- Any medical care costs not covered by insurance, which must
be paid by the insured.
– The total per year of medial expenses that an insured
pays forwards the health plan’s co-insurance. (ex; Health
plan’s coinsurance for the insured is 20% with a max out
of pocket of $3000 plus deducible).
Point-of-service plan (POS) - An
HMO plan that also incorporates an indemnity plan option (this
will be out of network care) allowing members to obtain medical
care from providers outside of the HMO network at a reduced
benefit and at greater out-of-pocket expense. You can decide
whether to go to a network provider for lower out of pocket
costs, or go to an out-of-network provider and higher out of
Policy - A written document that
contains the terms of the contractual agreement between an insurance
company and the owner of the policy.
Policy year - The
period of time that the policy is to remain in force; usually
12 full months.
Policy owner - The
person or business that owns an insurance policy.
PPO (preferred provider
organization) - An organization where providers are under
contract to an insurance company or health plan to provide care
at a discounted or negotiated rate. Typically, you can see any
doctor in the PPO network without requiring special approval,
and you usually do not need to choose a primary care physician.
Most PPOs will also allow you to seek care outside of the PPO
network; however, the benefits are usually reduced and the insured
has a greater out-of-pocket expense.
- For individual health insurance policies, an injury or a sickness
that occurred or manifested itself before the policy was issued.
For group health insurance policies, a condition for which an
individual was diagnosed or received medical care prior to the
effective date of his coverage.
provision - A health insurance policy provision stating
that benefits will not be paid for any illness and/or condition
that existed prior to one becoming an insured under the particular
health plan in question, until the insured has been covered
under the policy for a specified period.
Premium - A specified
amount of money that the insurer receives in exchange for its
promise to provide health insurance to an individual or a group.
Primary care physician (PCP)
- A doctor who serves as the insured's personal physician to
direct the course of your treatment and/or refer you to other
doctors and/or specialists in the network.
- The length of time that a new group member must wait before
becoming eligible to enroll in a group’s insurance plan.
Renewal date - The specified date
of when the health insurance coverage will renew for another
period, typically a year.
A group insurance plan under which the employer takes complete
responsibility for all claim payments and related expenses rather
than purchasing coverage from an insurance company.
- This type of coverage pays a percentage of your salary if
you become temporarily disabled, meaning that you are not able
to work for a short period of time due to sickness or injury
(excluding on-the-job injuries, which are covered by workers
compensation). The per-week amount is usually 50, 60 or 66 2/3
percent of your weekly salary, and lasts for a period of time
specified by the plan.
Standard industrial classification
(SIC Code) - The Standard Industrial Classification (SIC)
system is a series of number codes that attempts to classify
all business establishments by the types of products or services
they make available. Establishments engaged in the same activity,
whatever their size or type of ownership, are assigned the same
SIC code. These definitions are important for standardization.
Insurance companies use SIC codes to determine specific rates
for various industries. HealthInsurance.com uses these codes
to ensure that you receive the best possible rate for your occupation.
Stop-loss - A major
medical policy provision under which the insurer will pay 100
percent of the insured's eligible medical expenses after the
insured has incurred a specified amount of out-of-pocket expenses
in deductible and coinsurance payments.
Term life insurance - A type of
life insurance that provides a death benefit if the insured
dies during a specific period.
Underwriting - The process of identifying
and classifying the degree of risk represented by a proposed
Urgent care - Urgent
care is appropriate when a medical urgency arises which necessitates
immediate care, but has not reached a life or limb threatening
true emergency. Most managed care plans require you to seek
urgent care at a participating urgent care facility or hospital.
Usual, customary and reasonable
fee - The maximum dollar amount of a covered expense
that is considered eligible for reimbursement under a medial
or dental policy.