Aetna Health Insurance

AFFORDABLE TEXAS HEALTH INSURANCE PLANS

AETNA Healthcare Insurance

Compare plans alongside, get free health insurance online quotes, apply on the internet and buy Aetna health Aetna Healthcare Insurance has been around operation because the middle 1800s, when the organization released its initial life insurance coverage plan. Additionally to supplying nearly 15 million individuals with health care insurance and 13 million individuals with insurance each year, Aetna keeps a powerful presence in marketplaces, for example casualty, property, and pharmacy insurance.

Over 700,000 US health care professionals accept Aetna insurance, and the organization provides group insurance policy for roughly 13.six million people. If you’re interested in how to enroll in Aetna health care insurance for the small-scale or large-scale Georgia business, we at Metro Atlanta Financial Group could be grateful to expose you to a variety of disability, dental, group existence, lengthy-term, and health care packages through the organization.

Our services are 100 % free, and that we do the majority of our sales through recommendations. We now have maintained a good customer support history throughout our two decades conducting business in Georgia, and that we provide over-the-phone as well as in-person consultation services. It’s a snap to make use of our online forms to request more details in order to parse out various Aetna options.

Whether your firm is trying to find a perfect PPO intend to safeguard its officials and employees or maybe your small company desires to expand its coverage pallet, Metro Atlanta Financial Group might help. We all know the legal aspects, insurance rules, and statistics much better than any seller available, and that we are pleased to transmit you satisfied customer recommendations to provide you with a flavor of the items type of service we offer.

Insurance companies and reinsurers use catastrophe bonds to transfer major risks on the books, for example storms and earthquakes, to capital marketplaces traders, thus delivering capital to underwrite new insurance business. Aetna closed its three-year class A notes at $110 million, and also the Class B notes at $40 million stated S&P. Prices was elevated in the original guidance, arriving at 440 basis points over Libor for that Class A notes and also at 625 basis points over Libor for that Class B notes, based on S&P. Goldman Sachs, as repurchase counterparty, will enter master repurchase contracts with Vitality Re.

Aetna Corporation.’s (AET) first-quarter earnings rose 4% because the health insurance provider ongoing to profit from lower utilization of medical services, leading the handled care company to enhance its per-share earnings guidance for that year by 13%. The truth that Aetna’s medical cost ratio for that quarter am reduced than its peers is really a “head scratcher,” stated Jefferies analyst David Windley. Based on the health-care overhaul bill passed this past year, insurance companies must spend a specific amount on medical investing, referred to as a medical loss ratio. Commercial medical-loss ratio flooring is going to be implemented this year, while Medicare insurance flooring is going to be implemented in 2014. The most recent period incorporated internet capital gains of seven cents a share. Premium revenue dropped 2.4%.

Aetna has signed a contract to get Prodigy Health Group, a completely independent 3rd party administrator of self-funded health care plans. Health care benefits firm Aetna will acquire Prodigy Health Group from Prodigy Health Holdings whose majority owner is a Equity Partners. Aetna needs to invest in the purchase with available assets. The agreement enables Aetna to lessen its needed capital and offers $150m of collateralized more than loss reinsurance coverage on the part of Aetna’s group commercial medical health insurance business. Aetna – medical health insurance

Faster Dying Benefit (ADB)

An organization life insurance coverage feature that allows an associate or spouse who’s identified having a terminal illness or existence-restricting medical problem obtain a area of the existence benefits being an early payment.

Accidental Dying and Dismemberment (AD&D)

An advantage that’s due to some beneficiary for demise in order to an associate to have an accidental injuries, as specified by an insurance policy.

Accidental Dying and private Loss Coverage (AD&PL) or AD&D Ultra®

Covers exactly the same deficits as AD&D, but additionally pays an advantage for unpredicted occasions that increase the risk for lack of sight, speech and hearing paralysis coma and third-degree burns. Just in case of demise, benefits can also be readily available for education, day care and return of remains. Another advantage might be available when the member dies while correctly utilizing a passenger restraint system.

Active Full-Time Worker

An worker who works regularly within the usual span of the employer’s business. An worker must work on least the amount of hrs within the employer’s normal workweek or the amount of hrs as proven within the plan’s Schedule of Insurance.

Adjudication

The determination by an insurance provider or health plan from the accessibility to medical health insurance or health advantages for any claim and the amount of help to be compensated.

Aexcel

A designation by Aetna for several specialists who’ve met certain amounts of clinical performance and efficiency.

Age Discrimination Employment Act (ADEA)

A federal law that restrictions unfair and discriminatory treatment in employment because old.

Aggregate Maxium

The utmost benefit that’ll be compensated underneath the Insurance policy for all Covered Medical Expenses suffered by a Covered Person who accumulate in one year to another.

Alcohol & Drug Restriction

Any limit on period of benefits for disabilities associated with alcoholism and/or substance abuse.

Allowable Expense(s) (also called Covered Expense(s))

Any medically necessary and reasonable health expense, part or which is included under the health advantages or medical health insurance plans from the member to whom the claim is created.

Amalgam

A kind of filling comprised of a combination of several metallic materials. Amalgams are silver colored in most cases utilized on posterior, or back, teeth.

Ambulatory Surgery

Methods that don’t require an overnight remain in a healthcare facility or ambulatory surgery facility. These methods could be carried out within the hospital, a surgery center or physician office.

People in America with Disabilities Act (ADA)

A federal antidiscrimination law that allows qualified individuals with disabilities towards the same employment consideration as other people.

Any Occupation

Employment that one is qualified by education, training or experience.

Appeals

A procedure open to an associate to request the health plan reconsider an advantage denial or claim decision.

Authorization

The entire process of receiving approval for many healthcare, for example hospitalization, outpatient surgical procedures or prescription medications, prior to it being covered. So as to, qualifications and resolution of coverage could be confirmed and conveyed before an associate receives treatment or services.

B

Balance Billing

The entire process of billing an associate the main difference between your fee amount the taking part physician or hospital discussed using the insurance provider which doctor’s or hospital’s usual fee for any service or supply. Taking part doctors and hospitals agree to not bill the member for that distinction between both of these amounts.

Beneficiary

The individual(s) or entity that’s named through the member to get the quantity of his/her life insurance coverage and/or AD&D insurance, in case of his/her dying.

Benefit

Payment received for covered services underneath the relation to any adverse health insurance/health advantages plan or policy. Or even the amount due by an insurance provider to someone creating a claim, assignee or beneficiary under each coverage inside a group contract.

Benefit Duration

The utmost period of time that benefits are compensated while an worker has gone out on short-term disability (STD) and lengthy-term disability (LTD), following the worker meets the plan’s qualification period. Known as “commencement period” for STD and “elimination period” for LTD.

Benefit Period

The utmost period of time that benefits is going to be compensated.

Brand-Title Drug

A drug that’s offered within specific trade title with a pharmaceutical manufacturer. These medicine is under patent protection. A patent gives the organization that developed the drug exclusive privileges to create then sell that drug for some time period – usually two decades. When these privileges go out, other drug companies could make then sell generic versions from the drug.

C

Calculus (Also called Tartar)

If left without treatment, plaque can start to mineralize and harden into calculus or tartar.

Capitation

A set, prepaid amount a physician or hospital receives for each individual offered.

Caries

A phrase which means tooth decay or cavities.

Situation Management

A procedure of: determining people at high-risk for problems associated with complex healthcare needs and looking at methods to coordinate care.

Certification

The entire process of receiving approval for many healthcare, for example hospitalization, outpatient surgical procedures or prescription medications, prior to it being covered. So as to, qualifications and resolution of coverage could be confirmed and conveyed before an associate receives treatment or services.

Certification of a time of Disability

A procedure accustomed to determine and communicate whether an worker meets the phrase disabled within disability policy.

Chemotherapy

Management of cancer by chemical or biological drugs.

Chiropractic care

Therapy supplied by an authorized professional – a chiropractic specialist – who changes the spine and joints to deal with discomfort and improve overall health.

Claim

A request benefits payment for an insured worker or beneficiary (the claimant).

Closed Formulary

Describes pharmacy plans covering qualified prescription medications for auction on a frequent Drug List. It doesn’t include drugs around the Formulary Exclusions List. A medical exception is required to cover prescription medications around the Formulary Exclusions List.

Combined Life Insurance Coverage Maximum

The greatest total quantity of fundamental employer-compensated and supplemental worker-compensated life insurance coverage that might be released to candidates who’ve provided acceptable Proof of Insurability.

Common Law Marriage

A married relationship that’s not provided official by ceremony, but is produced by a contract to marry, then living together. It is simply recognized in certain states.

Complication of being pregnant

A celebration or procedure that happens throughout pregnancy that’s not connected having a normal pregnancy.

Composite

A kind of filling that suits natural tooth color. Composites are whitened in most cases utilized on anterior, or front, teeth.

Congenitally Missing Teeth

Teeth that never been around. This shouldn’t be wrongly identified as influenced teeth (teeth that never exploded). This can be a condition existing at or dating from birth.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

A 1986 federal law for group health plans covering 20 or even more employees. What the law states requires diets to carry on offering coverage to people who’d otherwise lose it. COBRA doesn’t need continuation of existence or disability insurance policy.

Contract (also called an advantage Certificate or Policy)

A legitimate agreement between a person customer or perhaps an employer group (contract-holder) along with a medical health insurance or health advantages plan that describes the advantages and restrictions from the coverage.

Contributory

Signifies that the price of an organization insurance policy is created simply through the employer and simply by employees.

Conversion Charge

The total amount billed towards the insurance holder whenever a covered member selects to transform group coverage for an individual policy.

Conversion Option

A choice that enables an associate to purchase individual life insurance coverage if he/she: manages to lose group coverage due to employment termination or retirement has less existing group coverage due to a lower amount because of age.

Coordination of advantages (COB)

A provision to assist avoid claims payment delays and duplication of advantages when one is included in several plans supplying benefits or services for medical, dental or any other care or treatment. One plan becomes the “primary” plan and also the other becomes the “secondary” plan. This determines a purchase where the plans pay their benefits.

Copay

The particular amount of money or percentage the member be forced to pay, or that must definitely be compensated with respect to an associate, when covered services are supplied.

Living costs Adjustment (COLA)

Optional lengthy-term disability benefit that delivers an annual percentage increase towards the monthly benefit received after breaks, usually for any defined period.

Covered Benefits (also called Covered Services)

Necessary services and supplies which are covered underneath the plan. They have to follow all of the conditions and terms from the group agreement or group insurance plan.

Covered Monthly Payroll (also called Covered Monthly Salary)

The quantity of monthly earnings accustomed to calculate the lengthy-term disability premium and disability benefit, taking into consideration the utmost monthly benefit within the plan.

Covered Weekly Benefit

The total amount accustomed to calculate the short-term disability premium and disability benefit, taking into consideration the utmost weekly benefit within the plan.

Credentialing

A procedure to judge a doctor’s qualifications and record of professional competence and conduct. The procedure includes overview of related training, academic background, experience, certification, certification and/or registration to rehearse inside a healthcare area.

Crown Lengthening

Removing gum tissue (gingiva) and bone, to reveal a lot of tooth’s structure. A dental professional will often perform crown lengthening whenever a tooth must be restored, but there’s insufficient tooth over the gumline to aid the crown or filling.

D

Date Claim Incurred (DCI)

Within disability contract, your day the physician who accounts for the claimant views him/her to become disabled.

Date Claim Received

The date the claim is received.

Date Last Labored (DLW)

For lengthy-term disability, the final day a claimant labored any area of the day. For brief-term disability, if your claimant labored under 1 / 2 of an ordinary scheduled day, the DLW is transformed to previous day labored. If your claimant labored one half day or even more, then your DLW is the fact that day.

Date of Disability (also called Date of Claim or Incurred Date)

The date the claimant grew to become disabled based on the policy or plan definition.

Day Treatment Facility

A psychological facility that’s licensed to supply outpatient care and management of mental and nervous conditions and/or drug abuse within doctor’s supervision.

Dying Benefit (also called Face Amount or Specified Amount)

How much money compensated towards the beneficiary when the insured dies.

Debridement

Removing excessive levels of plaque and tartar, which impair Pediatric Dentistry & Orthodontics dentist’s capability to examine one’s teeth. This really is carried out in rare occasions when the individual hasn’t were built with a dental cleaning in an exceedingly very long time along with a gross quantity of debris has generated up.

Deductible

Some money that the member be forced to pay for covered services, including prescription medications, inside a specified period of time, prior to the plan pays benefits.

Dependent

An individual who is qualified to get existence and/or medical health insurance Or wellness benefits coverage within plan’s provisions. Good examples will be the plan subscriber’s spouse, child or domestic partner, if offered.

Tests

Tests and methods purchased with a healthcare professional to find out if an individual includes a specific condition or disease according to signs or signs and symptoms. These could include radiology, ultrasound, nuclear medicine, and laboratory and pathology services or tests.

Immediate Access (also called Open Access)

Describes health advantages Or wellness insurance coverage that let an associate go to a taking part healthcare professional with no referral.

Disability

See Lengthy-Term Disability and Short-Term Disability

Disability – Extended Existence

A provision that enables the member’s life insurance coverage to stay essentially if he/she’s not able to work on his/her very own project for pay or profit. The disability should also avoid the worker from working at any reasonable job heOrshe might be appropriate for by education, training or experience.

Disability – Existence

Once the worker is not able to work on his/her very own project for pay or profit. The disability should also avoid the worker from working at any reasonable job heOrshe might be appropriate for by education, training or experience.

Disability and Absence Management

A comprehensive term for your loved ones of disability and absence management items and services.

Disability Extension

A provision that enables for ongoing life insurance coverage while an worker is disabled. Certain conditions should be met for coverage to become ongoing. Rates for ongoing coverage is going to be needed. The disability extension is applicable simply to worker fundamental and supplemental life insurance coverage.

Disability Payment

A payment received by an insured person due to a disability.

Disability Provision

A typical provision that continues life insurance coverage to have an worker who becomes permanently and totally disabled.

Disability Waiting Period – Extended Existence

The time an worker must continuously be absent from work, due to disease or injuries, to be able to be qualified for longer life insurance coverage.

Disease Management Program

A course available under some medical health insuranceOrwellness benefits plans that supports people with chronic – or long-term – conditions for example diabetes, bronchial asthma and cardiovascular disease. This program can include educational materials and member support for monitoring the problem and treatment.

Doc Find

A listing of healthcare professionals that’s available online. Accustomed to help people learn more about taking part doctors, hospitals, dental practitioners, pharmacy technician along with other companies within an area.

Domestic Partners

Generally describes unmarried, unrelated people who live together and have the effect of each other peoples welfare and obligations. Might be same-sex couples.

Durable Medical Equipment (DME)

Equipment that’s: designed for and mainly utilized in treating an illness or injuries made for use on the lengthy time period suited to use by someone who isn’t an inpatient within the hospital not normally useful to individuals who don’t possess a disease or injuries not to be used in changing quality of air or temperature not for exercise or training.

E

Earnings Definition

Refers back to the base weekly (short-term disability) or monthly (lengthy-term disability) obligations that exclude an individual’s bonuses, overtime or any other extra compensation. Some kinds of compensation, for example commissions, are incorporated or excluded with respect to the policy.

Effective Date

The date which the policy within member’s plan adopts effect at 12:01 a.m.

Qualifications

Insurance plan terms that comprise who’s qualified to obtain coverage and also the needs for receiving coverage. These could include period of employment using the plan sponsor, job status along with other provisions.

Elimination Period

Some time that the worker should be continuously disabled before disability benefits are due.

Emergency (also called Medical Emergency)

An urgent situation medical problem getting signs and symptoms which are severe enough (including sharp discomfort) it leads to a careful person, that has a typical understanding of health insurance and medicine, to reasonably expect the lack of immediate medical assistance to lead to: placing the healthiness of the person (or, having a pregnant lady, the healthiness of the lady and her unborn baby) in serious risk serious injury to bodily processes serious disorder associated with a wood or part.

Emergency Facility

Any adverse health facility that delivers short-term take care of medical situations or methods requiring immediate treatment. Includes urgent care centers, hospitals and walk-in treatment centers.

Endodontist

A verbal specialist who goodies illnesses from the tooth’s nerves or pulp, that is situated in the heart of your tooth as well as in waterways (known as root waterways) within each tooth root.

Enrollee

A customer or subscriber’s dependent who’s signed up for and included in any adverse health benefits/medical health insurance plan.

 

Proof of Insurability (EOI) (also called Medical Underwriting)

The entire process of doing a person and/or group risk analysis for somebody using for brand new or elevated coverage, where a healthy body should be proven. The EOI process might include: EOI statement – questions regarding medical and health conditions clarified by a job candidate Health check – made by a paramedical professional Tests, for example an EKG Report in the applicant’s physician More information if needed.

Exclusions

Specific conditions or conditions that aren’t covered for benefits within plan.

Experimental Services or Methods (also called Investigational)

Healthcare services, supplies, remedies or drug treatments that haven’t yet been determined to work and safe in dealing with the condition or injuries that their me is suggested.

Explanation of advantages (EOB)

An application that describes the way the payment amount for any health benefit/medical health insurance claim was calculated. Additionally, it may explain the claims appeal process and supply additional information.

F

Face Amount

How much money compensated towards the beneficiary when the insured dies.

Facility-of-Payment Provision

Enables an insurance provider to subtract a sum in the life insurance coverage benefit and pay it to some beneficiary, friend or relative prior to the final settlement from the claim.

Family Medical Leave Act (FMLA)

A federal law for companies with 50 or even more employees that allows qualified employees to some total of 12 workweeks of delinquent leave throughout any 12-month period for: proper care of a baby child inside the first 12 several weeks of existence adoption of or promote take care of a child inside the first 12 several weeks of positioning proper care of a spouse, child or parent from the worker if stricken having a serious health problem medical leave for that worker that has a significant health problem and can’t perform responsibilities from the job.

Formulary (also called Preferred Drug List)*

A listing from the prescription medications which are approved for coverage by most of the pharmacy benefits plans. It offers many brand-title and generic drugs authorized by the U.S. Fda (Food and drug administration). With different member’s plan, preferred drugs around the formulary might have lower copay than nonpreferred drugs.

Formulary Exclusion List

A listing of prescription medications that the pharmacy benefits plan doesn’t cover if your member goes to some closed-formulary plan. If it’s medically essential for an associate in this kind of plan to utilize a drug around the Exclusion List, the member’s physician must contact the Pharmacy Management Precertification Unit to request coverage like a medical exception.

Functional Capacity Evaluation

An exam of someone’s ability and readiness to carry out a full-range of activities, mostly relevant to some job. It could evaluate how good the individual can lift, bend, stand, climb or make fine-hands motions, and it is usually made by an work or physical counselor. *Many drugs onto it are susceptible to rebate plans between Aetna and also the manufacturer. The Most Well-liked Drug List is susceptible to change.

G

Generic Drug

A prescription drug that consists of exactly the same ingredients within the same amounts since it’s brand-title counterpart. The U.S. Fda (Food and drug administration) views generic drugs to become competitive with brand-title drugs. A normal drug usually can be offered once the patent on the brand-title drug expires.

Gingivitis

Swelling from the gum – or gingival — tissue triggered by plaque. Nicotine gums can happen red-colored, inflamed, and bleed easily throughout brushing. This is actually the beginning stage of periodontal disease.

Group Insurance

Insurance policy that’s open to people via a plan sponsor – usually a company. The accessible benefits are based on the program sponsor’s policy using the insurance provider. Guidelines contain detailed plan explanations, restrictions and exclusions for every kind of coverage.

Group Universal Existence (GUL)

An item that delivers ongoing life insurance coverage coverage while permitting the member to develop a fund which has tax advantages.

GSHIP

Graduate Student Medical Health Insurance Plan

Guarantee Problem Maximum.


The quantity of life insurance coverage as much as which a job candidate is guaranteed coverage underneath the group plan without requiring to supply Proof of Insurability.

H

Hard waiver

An insurance coverage enrollment procedure that requires showing or demonstrating proof in difficult copy that the student is correctly insured. It’s the process adopted to have an insurance requirement policy distributed by a college or condition regulation.

Health Advantages Plan

The insurance or health maintenance organization (HMO) product provided by an authorized health advantages Or wellness insurance provider. The program is dependant on an agreement and includes some covered services or expenses which are acquired through: a network of doctors along with other healthcare professionals or immediate access to licensed healthcare companies – like doctors – and facilities

Medical Health Insurance Portability and Accountability Act (HIPAA)

A federal law which was produced to enhance availability and portability – or transferability – of coverage of health by: restricting exclusions for pre-existing conditions giving credit for prior coverage of health permitting transfer of coverage information (for example covered family people and coverage period) to a different insurance provider making certain that individuals can subscribe to coverage of health once they lose existing coverage or possess a new dependent banning discrimination in sign-up and payment costs ensuring accessibility to medical health insurance coverage for small companies. HIPAA rules also enhance the efficiency from the healthcare system, by: supplying a typical method to digitally send health information and safeguarding the safety and privacy of knowledge that may identify an associate.

Health Maintenance Organization (HMO)

A kind of health advantages plan that arranges for health services that it is people need. Inside a traditional HMO plan, non-emergency services should be received from the network of healthcare professionals, even though some HMO plans may offer reduced benefits for care received outdoors from the network. In many HMO plans, people must select a doctor (PCP) in the network to supply routine care making recommendations for niche and hospital services when appropriate.

Home Healthcare

Skilled nursing along with other therapy supplied by a house healthcare agency in your home rather than inside a hospital or skilled nursing facility.

Home Infusion Therapy

Dealing with someone aware of drug therapy that’s given via a vein.

Hospice Care

Choose to support and lower discomfort for any crictally ill person, either with an inpatient or outpatient basis, and also to support their family. The aim would be to let crictally ill patients stay in familiar surroundings as lengthy as you possibly can.

Hospital

A business supplying inpatient and outpatient medical services, that is accredited like a hospital through the appropriate industry organizations, or else determined as meeting reasonable standards. A hospital might be an over-all, acute care, rehab or niche institution.

I

ID Card

A card provided with a health insurance provider that delivers details about the policy. It offers a distinctive member identification number along with a toll-free telephone number to make contact with member services.

In-Network

Refers back to the utilization of healthcare experts who take part in the plan’s provider and hospital network.

Indemnity Plan

A conventional plan that provides people versatility within their selection of healthcare professionals for covered expenses. People have the effect of finding care, getting precertification, having to pay for services provided, and delivering in claims for payment of covered services. Indemnity plans will often have out-of-pocket expenses for example insurance deductibles and copayments. The member be forced to pay these before any expenses are compensated underneath the plan. Benefit and lifetime maximums also apply.

Independent Health Check (IME)

A medical examination, by an impartial physician, that’s needed to assist determine disability.

Independent Practice Association (IPA)

A legitimate entity or number of doctors that contracts with handled care plans while keeping another practice. An associate who chooses an IPA like a primary care office generally is going to be known to specialists and hospitals associated with the IPA, unless of course the member’s medical needs exceed the capacity of individuals doctors.

Indexed Pre-disability Earnings

Fundamental monthly earnings essentially right before the date that disability began, modified on The month of January 1 following a first anniversary of great benefit obligations and every following anniversary. Each adjustment is dependant on the lesser of 10% or even the current annual percentage rise in the customer Cost Index, that is released through the U.S. Department at work. Is applicable to lengthy-term disability only.

Infusion Therapy

Cure that provides therapeutic agents with the vein. Including intravenous feeding and enteral diet, the delivery of nutrition in to the stomach by tube.

Injectable Drug

A liquid medicine that’s put in your body having a needle or perhaps a tool known as a syringe. The medicine may begin like a powder that’s combined with water. The prescription medication is put underneath the skin, right into a muscle, or right into a vein.

Inpatient Care

Service provided following a patient is accepted towards the hospital. Inpatient care lasts 24 hrs or even more.

Integrated Health insurance and Disability (IHD)

For people who’ve medical and disability coverage, refers back to the service that mixes focused situation management with individual contact.

InteliHealth®

A web-based health website for locating valuable details about current health problems, fitness tips and health-related items.

J

Job Analysis.

An in depth breakdown of the person’s job needs. Meeting with the worker and supervisor or watching the job place and also the job being carried out carries it out.

L

Lapse

Termination – or ending – of the policy because rates weren’t compensated towards the insurance provider or health plan.

Laser eye surgery (also called laser-aided in situ keratomileusis)

An image correction procedure that’s carried out utilizing a laser.

Late Entrant (also called Late Enrollee)

An worker who: doesn’t choose coverage within 31 times of first being qualified to do this, whether underneath the current policy or any prior group policy the individual was qualified to elect coverage under, and who enrolls for coverage following the finish from the yearly enrollment period or open enrollment period, or doesn’t choose coverage within 31 times of acquiring a dependent, but selects coverage later on.

Period of Disability (LOD)

The time that disability is licensed.

Level Amount Schedule (also called Flat Amount)

A benefits schedule to which all employees get the equivalent benefit. This may differ in line with the employee’s title.

Life Insurance Coverage

An advantage that pays a particular amount of money to some member’s beneficiary upon the dying from the member. It’s offered through plan sponsors like a group product or offered to people. You will find many different kinds, including term existence, whole existence, and group universal existence yet others. A policy defines qualifications, elimination periods, and conditions and terms.

Limitation

Restriction.

Lengthy-Term Disability (LTD)

An advantage that pays an worker a portion of his/her earnings when the worker is not able to dedicate yourself a long time period due to a non-work-related illness or injuries. A policy defines qualifications, elimination period, and conditions and terms.

LTD Pension Accrual

Benefit that delivers pension fund obligations simultaneously that the insured body’s collecting disability benefits (for that duration of the disability). It allows the insured collect a normal pension at retirement, without penalty for that duration of disability.

LTD Pension Supplement

Benefit that delivers to have an allowance, or a number of obligations designed to the insured person regularly, after retirement. It replaces pension benefits which were unearned due to a disability period.

M

Mail-Order Drugs (sometimes known Rx Home Delivery)

Prescription drug service for pharmacy people, who receive medicines by mail. They are prescription medications accustomed to treat chronic – or lengthy-term – conditions, for example joint disease, bronchial asthma, diabetes, high cholesterol levels, heart disease and hypertension.

Handled Care

Any kind of health plan by which people get access to a network of contracted healthcare professionals and hospitals, which requires approval of some services.

Master Policy

Obtain The Most Amount

The greatest benefit amount due underneath the plan design. It’s really a weekly amount (short-term disability), monthly amount (lengthy-term disability) or annual amount (existence).

Obtain The Most Period

A long period of time that disability benefits are due, once all plan the weather is met.

Maximum Drug Benefit

The greatest amount any adverse health benefits/medical health insurance plan pays to pay for the expense of prescription medications for any member along with a member’s family throughout a period. These periods might be one fourth year, a twelve months or contract year.

Medical Emergency

An urgent situation medical problem getting signs and symptoms which are severe enough (including sharp discomfort) it leads to a careful person, that has a typical understanding of health insurance and medicine, to reasonably expect the lack of immediate medical assistance to lead to: placing the healthiness of the person (or, having a pregnant lady, the healthiness of the lady and her unborn baby) in serious risk serious injury to bodily processes serious disorder associated with a wood or part.

Medical Evacuation

Whenever a member is evacuated for an appropriate medical facility because of an urgent situation medical situation.

Medical Underwriting

The entire process of doing a person and/or group risk analysis for somebody using for brand new or elevated coverage, where a healthy body should be proven. The EOI process might include: EOI statement – questions regarding medical and health conditions clarified by a job candidate Health check – made by a paramedical professional Tests, for example an EKG Report in the applicant’s physician More information if needed.

Medically Necessary

Services or supplies which are right for or in conjunction with the diagnosis based on recognized medical standards as referred to within the Covered Benefits portion of the plan. The word is applicable simply to the determination through the plan whether healthcare services are covered benefits. All services are susceptible to the exclusions and restrictions referred to within the plan documents.

Member (also called Enrollee)

A customer or subscriber’s dependent who’s signed up for and included in any adverse health benefits/medical health insurance plan.

Member Services

A department inside a medical health insurance Or wellness benefits company that can help people with questions regarding plan benefits and exclusions and, if a part of an agenda, selecting or altering a doctor (PCP). It’s arrived at by calling the toll-free telephone number around the member ID card.

Mental Disorder

A disorder that shows itself through poor or unusual physical, mental or behavior functioning. Treatment methods are generally supplied by a mental medical expert like a mental health specialist, psychiatrist or psychological social worker.

Minimum Benefit

Minimal benefit amount due within disability period no matter earnings using their company sources.

Monthly Benefit

A monthly sum due to some claimant as they Or she’s disabled.

N

National Advantage Program (NAP)*

Offers agreed-on rates for: many medical claims that will well be compensated as charged under many indemnity plans the out-of-network part of handled care plans emergency/medically necessary services not given inside the standard network.

National Committee for Quality Assurance (NCQA)

A completely independent, not-for-profit organization that examines how good any adverse health insurance/health advantages plan handles every part of their medical delivery system and is constantly on the improve healthcare for people.

National Medical Excellence Program®

Helps qualified people get covered strategy to solid organ transplants, bone marrow transplants, plus some other rare or complicated conditions at taking part facilities familiar with carrying out these types of services.

Necessary, Medically Necessary, Medically Necessary Services or Medical Necessity

Services or supplies which are right for or in conjunction with the diagnosis based on recognized medical standards as referred to within the Covered Benefits portion of the plan. The word is applicable simply to the determination through the plan whether healthcare services are covered benefits. All services are susceptible to the exclusions and restrictions referred to within the plan documents.

Network (also called Provider Network)

Doctors, hospitals along with other healthcare companies who’ve an agreement having a medical health insurance Or wellness benefits company to supply services in a discussed rate of payment.

Non-Work Disease

An illness that’s not, by any means, associated with employment or self-employment, or doesn’t result, by any means, from the disease or injuries that happens from this kind of activity.

Non-Work Injuries

An accidental injuries that doesn’t occur from or throughout any act associated with employment or self-employment, whether or this is not on a complete-time basis.

Noncontributory

Negligence the price of an organization insurance policy that’s compensated through the employer (might be part of or even the entire cost).

Nonparticipating Provider (also called Out-of-Network or Nonpreferred Care Provider)

Generally accustomed to mean healthcare professionals – like doctors – and hospitals that haven’t contracted having a health intend to provide services at reduced costs. *Aetna doesn’t credential, monitor or oversee individuals companies who participate through third-party contracts. Since you will find numerous factors that see whether a price reduction will be presented, Aetna is not able to ensure any degree of discount under the program.

O

Work Injuries/Disease

An injuries or disease caused by carrying out employment. In many states, an work injuries or disease is included by workers’ compensation.

Work Therapy

Treatment to revive a physically disabled person’s capability to perform activities for example walking, eating, consuming, dressing, toileting and bathing.

Open Formulary

Describes specific pharmacy benefits plans which cover all qualified prescription medications. During these plans, prescription medications might be covered at lower copays if they’re preferred and greater copays if they’re nonpreferred.

Dental and Maxillofacial Surgeon

A verbal specialist whose practice is restricted to surgical procedure around the mouth area and jaws.

Orthodontist

A verbal specialist whose practice is restricted towards the recognition, prevention, and correction of irregularities within the positioning from the teeth within their relationship towards the jaws.

Other Earnings Benefits (also called Offsets or Cutbacks)

Earnings presented to an worker (and family people) due to the disability period that the worker is declaring benefits underneath the plan. Other earnings benefits, for example Social Security disability, workers’ compensation and pensions, may reduce benefits obligations and reserves.

Out-of-Pocket Maximum

The greatest amount any adverse health plan member is needed to cover covered services outdoors of his/her benefits plan. When the member reaches the out-of-pocket maximum(s), the program pays 100% of expenses for covered services.

Outpatient Care

Care provided inside a clinic, er, hospital or non-hospital surgical center, without acknowledging the individual.

Outpatient Surgery (also called Ambulatory Surgery)

Methods that don’t require an overnight remain in a healthcare facility or ambulatory surgery facility. These methods could be carried out within the hospital, a surgery center or physician office.

Over-the-Counter (OTC) Drugs

Drugs that are being sold physician. They aren’t covered under most standard prescription benefits plans.

P

Palliative

Remedies that can be used for the immediate (temporary) relief of discomfort, less your final strategy to the patient’s condition.

Partial Day Treatment

An outpatient program provided by licensed psychological facilities which includes a day or evening treatment plan for mental health or drug abuse issues.

Partial Disability

A disease or injuries that prevents an insured worker from carrying out a number of functions of his/her normal work and results in the worker to earn 80% or a smaller amount of pre-disability earnings.

Taking part Pharmacy

A pharmacy which has a contract having a health intend to fill covered medications because of its clients.

Taking part Provider (also called Preferred Care Provider)

Any physician, hospital, skilled nursing facility, other individual or entity active in the delivery of healthcare or related services that contracts to supply covered services to people for any discussed charge.

PCP

Doctor who frequently functions because the primary gatekeeper in health plans. That’s, frequently the PCP must approval recommendations to specialists. Specifically in HMOs and somePPOs, all people must choose or are designated a PCP.

Child Dental professional (also called a Pedodontist)

A verbal specialist who goodies only children.

Pending Claim

Claims which has not been approved or refused.

Periapical

The tissue all around the finish from the tooth root.

Periodontal Disease (also called Periodontitis)

A disorder that affects the nicotine gums along with other structures supporting one’s teeth. Periodontal disease is really a chronic microbial infection coupled with inflammation. Bacteria grow in dental plaque, which stays towards the tooth or root surface near the nicotine gums, leading to swelling. If left without treatment, the bacteria and inflammation will spread and destroy the nicotine gums and supporting bone round the teeth.

Periodontist

A verbal specialist whose practice is restricted towards the prevention, diagnosis, and management of illnesses from the surrounding and supporting structures from the teeth.

Permanent and Total Disability

An insurance coverage contract provision that delivers installment or lump-sum obligations if an individual becomes permanently and totally disabled.

Permanent Partial Disability

Kind of workers’ compensation disability benefit that repays an worker a portion or perhaps a flat amount of money from the earnings he/she lost due to an work injuries or disease.

Pharmacy Copay (also called Pharmacy Copayment)

How much money an associate pays to some taking part pharmacy for prescription medications included in a pharmacy benefits plan.

Physical Rehabilitation

Treatment that utilizes exercise and physical movement to alleviate discomfort, restore use, promote healing and stop disability in an element of the body. The therapy can take part in care following a disease, illness, injuries or operation.

Plan

Plan Documents

The contractual plan documents, explaining the conditions and terms of coverage, which are presented to the program sponsor. They might range from the Group Agreement, Group Policy, and Certificate or Proof of Coverage (or Certificate of Insurance) or Review of Coverage or Benefits.

 

 

Plan Exclusions and Restrictions

Binding conditions and terms which are put on insurance coverage. They might make reference to services, specific kinds of coverage, pre-existing conditions and/or any other restrictions.

Plan Maximum

The finest quantity of benefits that’ll be compensated under insurance coverage.

Plan Sponsor

The business, usually a company, that any adverse health benefits/medical health insurance or group insurance plan is released.

Point-of-Service (POS)

Any adverse health benefits plan that delivers coverage for care received from both taking part companies – for example doctors and hospitals – and non-taking part companies. In lots of POS plans, patients whose care is directed through recommendations using their doctor (PCP) get a greater degree of benefits, while patients who go straight to other doctors or facilities get a lower degree of benefits.

Policy (also called an organization Plan or Contract)

An agreement between an insurance provider along with a group (usually a company) or perhaps an individual customer, which describes the provisions, benefits and restrictions of coverage.

Portability

The entire process of receiving approval for many healthcare, for example hospitalization, outpatient surgical procedures or prescription medications, prior to it being covered. So as to, qualifications and resolution of coverage could be confirmed and conveyed before an associate receives treatment or services.

Pre-Disability Earnings (PDE)

The weekly or rate per month of fundamental earnings essentially at the time before becoming disabled.

Pre-Existing Condition

A physical disease (apart from pregnancy) or condition which was identified or treated throughout a particular time before enrollment inside a new insurance policy. Some pre-existing conditions might be excluded from coverage throughout a particular time following the effective date of coverage inside a new plan.

Preauthorization/Pre certification (a.k.a. Authorization, Certification, or Prior Authorization)

The entire process of receiving approval for many healthcare, for example hospitalization, outpatient surgical procedures or prescription medications, prior to it being covered. So as to, qualifications and resolution of coverage could be confirmed and conveyed before an associate receives treatment or services.

Preferred Care Provider

Any physician, hospital, skilled nursing facility, other individual or entity active in the delivery of healthcare or related services that contracts to supply covered services to people for any discussed charge.

Preferred Drug List

A listing from the prescription medications which are approved for coverage by most of the pharmacy benefits plans. It offers many brand-title and generic drugs authorized by the U.S. Fda (Food and drug administration). With different member’s plan, preferred drugs around the formulary might have lower copay than nonpreferred drugs.

Preferred Provider Organization (PPO)

Any adverse health benefits plan that allows people choose any physician or hospital without naming a principal care physician. It provides incentives, usually as lower obligations for services, to people that like preferred, or perhaps in-network, doctors or hospitals.

Premium

The charge or charges incurred to get coverage by an insurance provider or company.

Premium Waiver (PW)

An agreement feature where the insurance provider concurs to carry on life insurance coverage for any disabled worker without premium obligations, in line with the policy conditions and terms.

Prescription

A doctor’s order for any prescription drug. If it’s a verbal order, it has to quickly be placed on paper through the pharmacy.

Prescription Drug

A drug that, legally, is offered just with a doctor’s written or verbal order.

Maintenance

Programs or services that will help look after you, for example annual physical exams, or should identify early signs and symptoms of health issues or disease, for example mammograms and colon cancer tests.

Doctor (PCP)

A taking part physician who coordinates and offers choose to people, as well as gives recommendations for specialist care. A PCP could be a general or family care physician, an internist or doctor.

Prophylaxis

A routine service carried out to prevent dental problems for example periodontal disease and caries. It offers a comprehensive scaling (elimination of tartar over the gumline) and sprucing up from the teeth to get rid of plaque and stains.

Prosthetic Products

Something, which replaces any some of the body part. These products are essential since the part of the body is permanently broken, missing or otherwise working correctly.

Prosthodontist

A verbal specialist whose practice is restricted towards the restoration or upkeep of function by alternative of natural teeth.

Provider

An authorized healthcare facility, program, agency, physician or medical expert that provides healthcare services.

Provider Network

Doctors, hospitals along with other healthcare companies who’ve an agreement having a medical health insurance Or wellness benefits company to supply services in a discussed rate of payment.

Q

Quadrant

Among the four equal sections into that the dental archways could be divided. A quadrant starts in the midline from the arch and stretches towards the last tooth situated at the rear of the mouth.

R

Radiotherapy

Management of an illness by X-ray, radium, cobalt or high-energy particle sources.

Rate

The costs to get coverage from an insurance provider or company sometimes categorized by customer and extra loved ones.

Reasonable Occupation or Job

Any compensated project for that your disabled worker is, or may reasonably become, suited by training, education or experience.

Rebate

The alternative from the entire base of the denture without altering one’s teeth. Normally, this is completed to balance alterations in the supporting tissue.

Recurrent Disability

Happens after an individual has met the advantage Elimination Period and qualified for disability benefits underneath the plan. It’s then a recovery period an additional duration of “total disability.” The 2nd duration of disability might not be separated in the first duration of disability for over a number of months and should be triggered through the same or related condition. Generally, a policy must stay in pressure for that provision to use.

 

Referral.


Specific directions or instructions from the member’s PCP that direct an associate to some taking part healthcare professional for medically necessary care. A referral might be written or electronic.

Rehab Engineering

Using understanding, abilities, techniques or technology to assist a disabled person fully take part in his/her job, community and activities of everyday living. It may be as complex like a voice-triggered computer or as easy as a block of wood within desk to really make it more accessible to someone inside a motorized wheel chair. Additionally, it may involve restructuring job responsibilities.

Rehab Program

Involves physical, mental or vocational services and supplies which help improve or restore an employee’s health insurance and well-being so he/she can go back to work. This program is dependant on medical evidence and the opportunity of go back to “own occupation” or perhaps a reasonable occupation on the full-time basis or the finest period of time possible.

Related Absences

Several periods of absence from work which are related in diagnosis and separated with a period of time based on anything. However, the go back to work/nondisabled period falls inside the being approved period.

Reline

A process carried out to resurface negligence the denture that matches from the gum tissue.

Respiratory system Therapy

Management of illness or disease made by getting dry or moist gases in to the lung area.

Retired person

An old worker who meets minimum age and years-of-service needs, that are based on the business.

Retirement Rule

Rule that determines the advantage amounts open to upon the market employees.

Return-To-Work Incentive (RTW)

Allows employees go back to work part-time as lengthy as the sum of the disability benefits and current earnings is under 100% of modified pre-disability earnings.

Root Canal

Removing inflamed, infected or broken pulp (ligament, nerves and bloodstream ships that nourish your tooth) from either the middle of your tooth or in the waterways within each tooth root. When the infection is treated the empty waterways are full of an inert, or inactive, material, with the aim of getting rid of the requirement for extraction.

Root Planing and Scaling

Removing plaque and calculus in the area below the gumline, across the root. This removing from the root surface is carried out to assist take away the uneven surface that will allow bacteria to add easily.

S

Salary Continuation

A proper benefits enter in which a company continues any a portion of the employee’s salary as the worker is disabled on the short-term basis.

Second Opinion

The option or requirement to go to another physician or surgeon to have an opinion in regards to a diagnosis, treatment or kind of optional surgery to become carried out.

Service Area

The geographic area the HMO or PPO is licensed to use in or, when certification isn’t needed, the region where an sufficient network is available to supply covered services.

SHIP

Student Medical Health Insurance Program

Short-Term Disability (STD)

An advantage that pays an worker a portion of his/her earnings when the worker is not able to dedicate yourself a restricted time period due to a non-work-related illness or injuries. The STD policy defines qualifications needs, elimination periods, and conditions and terms.

Skilled Nursing Facility (SNF)

An institution or part of an institution that’s licensed or approved under condition or local law to supply skilled nursing care and related services like a Skilled Nursing Facility, extended care facility or nursing care facility. It should be authorized by the appropriate industry organizations.

Specialist

A physician who provides health care in a generally recognized medical or surgical niche area.

Speech Therapy

Treatment to fix an address problem present from birth, or triggered by disease, injuries or earlier treatment.

Customer

The worker covered under an employer’s group agreement or group insurance plan. The customer can register qualified loved ones, as based on a policy, under family coverage.

Successive Disabilities

Several periods of disability which are related in diagnosis and separated by some time based on anything.

Supplemental Life Insurance Coverage

Additional life insurance coverage which people buy beyond the quantity of fundamental coverage taken care of through the employer.

Survivor Benefit

Provides benefits payment for an qualified survivor following a disabled insured person has died.

T

Temporary Partial Disability

Kind of a workers’ compensation benefit that delivers for any lack of earnings for an worker that has a brief partial disability.

Temporary Total Disability

Kind of a workers’ compensation benefit that delivers for any lack of earnings for an worker that has a brief total disability.

Temporomandibular Joint Disorder (TMJ)

Several problems that modify the jaw joint, and/or even the muscles that control eating and moving the jaw.

Term Insurance

Life insurance coverage that continues to be in pressure only throughout the time – or term – that rates are compensated. It doesn’t develop cash value.

Tertiary Care

Specialized health care, usually on the very long time period, which involves complex methods made by medical specialists in condition-of-the-art facilities.

Total Disability – Any Occupation

The lack of ability to do the functions associated with a job due to a disease or injuries. It is dependent upon factors such work experience, job history or even the employment market.

Total Disability – Own Occupation

The lack of ability to do the functions of a person’s own job due to illness or injuries.

Transferable Abilities Analysis

An in depth study of specific abilities an individual can perform regardless of any crippling conditions. It offers overview of past jobs and education, in addition to hobbies and household activities, to be able to create a listing of abilities that could be moved to other kinds of employment.

U

Urgent Care

Services received to have an unpredicted illness or injuries that’s not existence threatening but requires immediate outpatient health care. An unexpected emergency requires prompt medical assistance to prevent problems and unnecessary or severe discomfort, like a high fever.

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V

Voluntary Plans

Signifies the entire price of an organization insurance policy is down to the worker, without any contributions through the employer.

W

W-2

An application that’s accustomed to report an individual’s earnings towards the Irs.

Weekly Benefit

An every week sum due to some claimant as theyOrshe’s disabled. It’s susceptible to the group short-term disability insurance plan (fully insured) or short-term disability plan document (ASC).

Well Baby/Well Day Care

The routine care, testing, examinations and shots for any generally healthy child from birth through age eight.

Wellness Program

Any adverse health management program which includes disease prevention, medical self-care and health promotion. It concentrates on stopping illness and disability.

Work Adjustment

A method to assist a staff improves work abilities and attitudes to ensure that he/she functions in a competitive level at work. This could take the type of one-on-one counseling or perhaps a free trial of carefully supervised operate in a rehab center. It’s frequently used when employees happen to be from the labor force for any lengthy time period, with people who’ve learning or psychological problems.

Workers’ Compensation

Legally protected benefits, including medical and disability earnings, for injuries associated with the task. It’s available in most 50 states, American Samoa, Guam, Puerto Rico and also the U.S. Virgin Islands.

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