Page 21 - 2016 Benefit Booklet AYN

Page 21

Glossary of Terms
Allowable Amount-the charge that the carrier determines as reasonable for
covered services provided to a member.
Benefit Period-the period of time during which charges for covered services
provided to a member must be incurred in order to be eligible for payment from
the carrier.
Coinsurance-the sharing of charges by the insurance company and the
member for covered services received by a member.
Coinsurance maximum-the maximum amount of coinsurance that a member is
obligated to pay for covered services per benefit period.
Conversion-the option to convert a group policy to an individual policy upon
termination of employment without giving information about your health.
Copay-the fixed-dollar amount which is due and payable by the member at the
time a covered service is provided.
Deductible-the specified dollar amount for certain covered services that the
member must incur before benefits are payable for the remaining covered
services. The deductible does not include copays or prescriptions.
Evidence of insurability-the ability to apply for and receive coverage based on
the guidelines of the carrier, may involve answering health questions and/or
medical exam.
Generic-a drug name not protected by a trademark.
In-Network-Providers and facilities that are contracted with a carrier to provide
services to members of that carrier’s plan(s) at a cost determined by the contract,
usually a lesser amount than patients without insurance coverage.
Late enrollee-an employee or dependent who fails to enroll in the plan within 30
days of becoming eligible
Non-Network-when a member receives services through a non-contracted
provider or facility, benefits are paid by the carrier at a lesser amount. Members
may be required to pay the provider/facility in full and be reimbursed by the
carrier.
Own Occupation-to perform each of the main duties of his or her regular
occupation.
Portability-the ability to obtain life/ad&d insurance when this policy ends prior to the
insured turning age 70, due to reasons stated in the certificate, without providing
evidence of good health.
Pre-existing condition waiting period-late enrollees are subject to a waiting period
of up to 12 months for pre-existing conditions (any condition for which treatment was
sought or which has been diagnosed in the past 3 months).
Usual, customary, & reasonable (UCR)-the dentist’s usual charge for the
service furnished, the charge made for the given dental condition isn’t more than the
usual charge made by most other dentists.