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What are “carve-outs” in health insurance?

Carve-out plans take specific diseases or categories of services and place them under control of a third party managed care organization. Usually, the carve-out involves higher priced services that will require additional payments from employees and beneficiaries. Some carve-outs involve specialized fields like mental health and drug abuse. The second type of carve-out creates employee […]

What does “PD” stand for in health insurance?

Prescription drugs and the rising costs of them are central themes in health care in the US. As a background fact, drug prices are significantly higher in the US than in other similar advanced societies. There are many examples of designer brand drugs that cost three to four times more in the US than in […]

What is a grandfathered medical plan?

A Grandfathered health plan is one that existed before the Affordable Care Act, and that the rules excused from meeting all of the requirements of the law. Grandfathered plans may continue to serve the membership existing as of the time Obamacare went into effect. The Individual Mandate The Affordable Care Act required every eligible resident […]

What is “actuarial value” in health insurance?

The Affordable Care Act reformed the insurance industry by requiring better policy coverage for consumers. The law sought to ban flimsy policies that provided far less protection than was needed for prices that far outweighed their value. Congress weighed facts and evidence about cost sharing in major medical coverage among large groups and public employees. […]

What is an “out-of-pocket maximum” in health insurance?

The Affordable Care Act was an attempt to reform the health insurance industry to lower national health costs and favor the rights of consumers. The primary protections included limits on deductibles and out-of-pocket expenses. One of the fundamental goals of Obamacare was to protect consumers against burdensome health care costs. The rising costs of medical […]

What is “stop-loss” in health insurance?

Stop-loss coverage is a much needed financial protection for any company that decides to self-insure employees for medical benefits. It is different from a health insurance policy in that the insurer does not pay for any medical services, but simply reimburses the company for any amounts over the liability amount. Enter your zip code above […]

What is a “lifetime maximum benefit” in health insurance?

The lifetime maximum benefit provision was a standard feature of health insurance contracts before the Affordable Care Act of 2010. These provisions placed a dollar limit on the amount an insurer would pay for a specific benefit. Once reached, the cap or limit would block further payments for the lifetime of the insured. Insurance companies […]

What is a Cadillac medical plan?

Some health plans provide unusually thorough and complete coverage. They often have no deductibles, charge few if any copays, and ask little or no coinsurance. The benefits are extensive and coverage for nearly every condition or illness. These so-called high-end, or Cadillac plans, reward policyholders with benefits equivalent to $thousands in additional income. As untaxed […]

What is a single payer health insurance plan?

Single payer is a fund that pays healthcare costs for a group. In national healthcare settings, single payer funds pay medical costs for every eligible resident of a state or nation. The single payer fund can work with many types of medical care arrangements. Single-payer national health insurance is an option for the US healthcare […]

What is HIPPA?

HIPAA is often considered to be a landmark piece of healthcare legislation. It is split into two parts, called Title I and Title II. HIPAA was passed in 1996 and signed into law by Bill Clinton. Title I covers health insurance coverage for people when they lose or simply change jobs. Title II covers what […]

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