Supervising the details and routine activities of installing and running a health plan, such as answering questions, enrolling individuals, billing and collecting premiums, and similar duties.

The legal contract outlining the full benefits, eligibility and procedures followed by your insurance company for your coverage. A “benefit grid” or “schedule of benefits” is a brief overview of the Policy, and the Policy has more of the specifics and legal guidelines.

In Cayman, when a person is covered on a Cayman-compliant plan for 12 or more months with no more than a 3 month break in coverage, the person is said to be portable to their next Cayman-compliant plan up to similar coverage levels which the prior coverage had. Financial accumulators, such as lifetime maximum and annual maximum, and prior exclusions / restrictions may be carried forward by the new insurer. However, no new exclusions or limitations may be placed on the new Policy (unless the applicant fails to disclose). If the person is applying to an upgraded coverage, the insurer may limit the new plan to their prior plan levels.

An internet service which most insurers offer in which you can sign up to be able to view your Explanations of Benefits (EOBs) and other insurance information on-line.

Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.

Also called coverage determination. A decision by your health plan about whether a service is medically-necessary and covered by the Policy. Often certain types of care or dollar amounts trigger the need for the insurer to pre-authorise services. Note that proposed fees do not have to be submitted by the provider for a pre-authorisation so the patient is advised to ask about the fees vs. coverage levels too.

Approval by a case manager or insurance company representative for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-certification often must be obtained by the individual. The goal of pre-certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary).

A condition that exists before your health insurance went into effect. These may be limited within your coverage depending upon your portability and your Policy provisions.

Always in USA and sometimes in other countries: a network of medical providers who are under contract with your insurance company for accepting assignment of covered benefits and usually provide discounts on costs. Be sure to use the PPO when available for best coverage levels.

Payments that you or your employer pay to the health insurance company to keep you insured.

A health care professional (usually a physician) who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a “quarterback” for an individual’s medical care, referring the individual to more specialized physicians for specialist care.

Refers to entities (persons or facilities) who provide medical, dental, vision or pharmacy services.