Individual Health Insurance Guide

Individual Health Insurance Glossary
Agent. An individual licensed      Cost Sharing. T...
Celtic Insurance Company
233 S. Wacker Drive
Suite 700
Chicago, IL 60606

Consumer Sales Contact Information
Phone: (800) ...
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Individual Health Insurance Glossary

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Individual Health Insurance Glossary

  1. 1. 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 tion. 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.
  2. 2. Celtic Insurance Company 233 S. Wacker Drive Suite 700 Chicago, IL 60606 Consumer Sales Contact Information Phone: (800) 779-7989 E-mail: Web.Reply@celtic-net.com www.celtic-net.com 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.

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