Individual Health Insurance Guide
Individual Health Insurance Glossary
Agent. An individual licensed Cost Sharing. The sharing of Network Providers. Limited Rider (Exclusion). An
by the state who sells insur- costs between the insurance grouping or panels of provid- amendment to an insurance
ance products and services to company and the insured per- ers in a PPO arrangement. policy that limits or excludes
the public. son through deductibles, co- Insureds may be required to medical services or supplies.
insurance and co-payments. use only network providers. For example, a rider to a
Annual Plan Deductible. A There is additional liability to policy may exclude coverage
specific dollar amount that the Coverage. The benefits that the insured for using non- for treatment to an appli-
insured must pay out-of- are eligible under an insur- network providers for medical cant's knee.
pocket each year before the ance policy, depending on services.
insurance company will make plan choices made by the Underwriting. The process
any benefit payments for applicant. Out-of-pocket maximum of determining whether or
claims. (OOPM). The maximum not the insurance company
Effective Date. The date amount that an insured is will accept an insurance
Applicant. The person apply- health insurance begins. required to pay under an application or what condi-
ing for an insurance policy. insurance policy per year. tions will not be covered
Eligible Expense. The portion
along with any changes to
Benefit. Amount an insurance of the medical care provider's Participating Provider. A the premium due to under-
company pays to an insured services that is allowed for provider who has agreed to writing.
person, assignee, or benefici- calculation of payment under contract with a PPO to provide
ary when the insured suffers a the terms of the insurance services to covered persons Sources: www.ahip.org,
loss covered by the insurance policy. at a discounted rate. www.ehealthinsurance.com,
policy. www.nahu.org, www.kff.org,
Exclusion. Specific condi- Renewal. Continuance of www.askme3.org
Benefit Options. Insurance tions, services or procedures coverage under a policy be-
benefits not included in the listed in the insurance policy yond its original term by the
policy which are available to for which the insurance insurance company’s accep-
the individual as an option at company will not provide tance of the premium for a
an additional premium. coverage or benefit payment. new term for the policy.
Claim. A request by the in- First-dollar Benefit. Eligible Pre-existing Condition. A
sured person or provider that medical expense for which the health condition that existed
benefits be paid on a covered insurance policy begins to pay before the effective date of the
health care service or supply. claims without first requiring insurance policy.
the insured to make an out-of-
Coinsurance. The payment pocket contribution. Pre-existing Condition
percentage an insured is re- Clause. A provision in an in-
quired to pay for a medical Lapse. Termination of an surance policy that outlines
claim, apart from any copay- insurance policy due to the definition of what is con-
ments or deductibles. For ex- non-payment of premiums. sidered a pre-existing condi-
ample, if an 80%/20% ar- tion and that benefits are not
rangement is chosen, the in- Mandated Benefits. Benefits
paid for a pre-existing condi-
sured pays 20% of the eligible for medical conditions
covered amount and the insur- required by state or federal
ance company pays 80%. law to be included in health Premium. Periodic payment
insurance policies. to keep an insurance policy in
Condition. Disease, illness, force.
ailment, injury, bodily malfunc- Negotiated Fees. Service
tion, or pregnancy of an indi- fees agreed upon by Preferred Preventive Care. Specified
vidual. Provider Organizations wellness and health promotion
(PPOs) and providers (doctors Questions? Celtic Consumer
services that may be part of Sales Representatives are
Copayment. A specific and hospitals). Rates are usu- the benefits package of an available to help. Simply call
charge an insured person ally based on services as de- insurance policy. (800) 779-7989 Monday-
pays to a provider for a spe- fined in the provider contract Thursday 8a.m.-5p.m. CST
cific health care service at the with the PPO, generally at a Reasonable and Customary. or Friday 8a.m.-4:15p.m CST.
time it is received. For exam- discount from what the pro- The maximum amount an Or send an e-mail to
ple, an insured may pay a vider would usually charge. insurance contract will con- Web.Reply@celtic-net.com.
“$35 office visit copay” accord- Participating providers cannot sider eligible for reimburse-
ing to the insurance policy. charge more than this agreed ment, based upon prevailing
upon amount. fees in a geographic area.
Celtic Insurance Company
233 S. Wacker Drive
Chicago, IL 60606
Consumer Sales Contact Information
Phone: (800) 779-7989
Celtic Insurance Company is a strong, committed, financially
stable individual health insurance company specializing in
quality individual health insurance. We aim to provide our custom-
ers with innovative, consumer-oriented products and services that
are easy to understand, access and use.
Our plans offer customers of all ages essential coverage while
giving them control over their health care decisions. We have a
wide-range of benefits and options to meet the diverse needs of
people in rural, suburban and urban areas.
With the help of technology, we make our application process fast
and easy, provide learning tools so individuals can choose the right
plan and understand their benefits, quickly find providers, refill
prescriptions and email customer service representatives all online.
Important Note: The information In applying for coverage, the pri- Celtic Insurance Company does
contained in this document and in mary insured agrees to be bound not provide tax, investment or
any accompanying literature is not by the Certificate. The benefits legal advice. Federal and state tax
intended to provide full details of described in these pages and any laws may change and are subject
Celtic plans and may change at accompanying literature are the to interpretation. If tax, investment
the discretion of Celtic Insurance standard benefits offered by or legal advice is requested, con-
Company. Complete terms of Celtic. Policy provisions vary in sumers should seek the services
coverage are outlined in the indi- some states. Plan availability and of a licensed professional.
vidual Certificate Booklets and set benefits may vary by state.
forth in the applicable insurance 9002C5150
Policy and Trust agreement.