Insurance has its own language. Here are terms PEBB uses to communicate about insurance benefits.
Insurer: Company licensed to take on risk. An individual or group pays premiums to the insurer. If claims are higher than premiums, the insurer pays the difference. If claims are lower than premiums, the insurer keeps the balance.
Self-insure: Group or organization takes on risk instead of paying an insurer to do so. If claims are higher than premiums, the organization pays the difference using funds held in reserve. If claims are lower than premiums, the organization keeps the difference to build the reserve.
Administrator: TPA or ASO that receives a fee for such services as processing claims, collecting premiums, contracting with provider networks and processing enrollment
Claim: Bill a provider or member submits to the plan for covered goods or services
Co-insurance: A percentage of the cost of covered goods or services paid by the subscriber
Co-payment (co-pay): A set amount the subscriber pays for covered goods or services
Coverage: Goods and services included in the design of a health plan.
Deductible: The amount a subscriber pays for covered goods or services before the plan begins to pay claims
Health Plan: Medical and dental benefits available through enrollment
Network: Set of providers who contract to provide goods and services of the health plan, submit claims for those goods and services and accept contracted rates
Plan Design: Selection of goods and services that are included in premium payments and paid in part or full through claims, co-insurance or co-payments
Provider: Individual or facility licensed to provide healthcare services
Participating Provider: For PEBB’s Statewide Plan in 2010, a provider who contracts to be in the Plan’s network. For the Regence plan in 2009, a provider who is not in the preferred network but participates in the claims process
Preferred Provider: Provider in the Providence Preferred network or a Provider that contracts with Regence to be in their preferred network