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A pre-existing condition is a health condition, injury, or sickness you have already been diagnosed with or received treatment for prior to enrollment in a new health plan.

In 1996, as part of the HIPAA legislation, federal law was instated to cover portability of insurance known as Consolidated Omnibus Budget Reconciliation Act or COBRA. This law requires that employers continue to provide the same health insurance coverage to ex-employees for a specific amount of time, typically 18 months.

Unfortunately, a company can change insurance carriers every year. This is probably occurring due to increasing rates, which are sometimes upward of 30%. They are probably having multiple carriers bid on your company's account and then going with the carrier that offers the lowest cost increase. This is a method used by some companies to maintain health care cost increases.

Your deductible (the amount you have to pay out of your own pocket toward healthcare services before your insurer starts to pay for covered services) affects the cost of your monthly premium. Generally, the lower the deductible, the higher the monthly premium.

Your healthcare provider would ask you to sign a promissory note if you are agreeing to receive care that is not covered by your insurer.

Typically, the deductible is not the maximum amount you can expect to pay out of your own pocket for your healthcare in a given year. It represents the amount you are responsible for paying before your insurance carrier begins to cover a greater percentage of service costs.

Typically, the deductible is not the maximum amount you can expect to pay out of your own pocket for your healthcare in a given year. It represents the amount you are responsible for paying before your insurance carrier begins to cover a greater percentage of service costs.

Primary insurance is the first insurer when more than one insurance policy provides concurrent coverage. The primary insurance often sets the allowed amount that a provider is able to bill. There is a coordination of benefits that must take place when there is more than one insurance in effect. Benefits from a primary insurer must be completed before submitting a claim to a secondary insurer. Secondary insurance usually covers services not covered or not completely covered by the primary insurance. It’s common, for example, for a person insured by Medicare to have secondary insurance to cover prescription costs and additional medical expenses.

A health condition, injury, or sickness for which you have already received a diagnosis or treatment prior to enrollment in a new health plan is called a pre-existing condition. Depending on the new health insurance plan, the participant may be subject to a waiting period before they can receive care for that condition. Often if the patient does not disclose their pre-existing conditions, any treatment for that condition or injury could be denied coverage indefinitely.

A medical claim can be denied for a number of reasons including: you hit your maximum lifetime benefit (although this is uncommon); you received a non-covered or experimental treatment; you have a pre-existing condition that is still outside of the coverage; or you experience a lapse in coverage and a health event manifests during that period of time when you did not have coverage.

A PCP is a primary care physician who acts as a gatekeeper for medical services. Typically required in an HMO plan, the PCP authorizes referrals to specialists or other doctors if deemed necessary. However, emergency medical care does not require prior authorization by a PCP.

Preventive care includes services such as disease screenings, immunizations, and counseling services delivered by providers. Unlike curative care, the purpose of preventive care is to prevent disease or diagnose health conditions early on to start initial treatment.

Some of the benefits of group plans are that they usually offer lower premiums than comparable individual policies and provide coverage that is more extensive. This is because in larger groups, the healthcare risk can be spread amongst greater numbers of people increasing average capability while reducing use.

Premiums vary for a number of reasons. First, different insurers get different rates with providers depending on their leverage or because some plans include providers who get reimbursed at a higher rate. The size of the group covered can also play a big role in the cost of health insurance. The bigger the group, the easier it is to assess, and the more people over whom the risk can spread. This often results in a lower rate, while a smaller group often results in a higher rate. Of course, there are always exceptions. For example, if a larger company has an older workforce, they may see higher rates because frequency and severity of health issues tend to increase with age.

Disease management programs are employer-sponsored programs that encourage better health practices among their employees and family in order to decrease healthcare costs.

It’s not an easy thing to tell. Self-funded companies generally contract with a TPA or insurance company to administer their healthcare, and companies with as few as 25 employees may be self-funded. So, you might have a large insurance company’s care, but that doesn’t mean it is your insurer. It may just be the network your company’s TPA uses.

A Health Savings Account, or HSA, is a savings account from which medical expenses are paid until you reach your deductible. For an HSA, money does not evaporate at the end of the policy period. An HSA is used in conjunction with a PPO network and is associated with a high deductible health plan.

A Flexible Spending Account, or FSA, is a “use it or lose it” plan. Under an FSA, your employer funds an account for you for medical needs, although it can also be used for a lot of other purposes (i.e. daycare expenditures). You can contribute you own money to the account with pre-tax dollars. If you do not use all of the money funded by your employer in a given year, your employer pulls the money back.

A Health Reimbursement Account, or HRA, is an IRS-approved arrangement between the employer and employee where healthcare expenses are reimbursed to the employee after initial payment. The employer reimburses only pre-approved healthcare expenses.

When a claim is denied, it typically means that you will be responsible for paying 100% of the cost of the services and visit to your doctor. So the deductible payment you already made should be applied to the amount that you owe the provider.