Plan Information
What does “network” mean in health insurance?
A group of contracted healthcare providers offering services at negotiated rates.
This plan requires a referral and limits coverage to in-network providers.
HMO (Health Maintenance Organization)
What does COB stand for?
Coordination of Benefits
What happens after you reach your Out-of-Pocket Maximum?
Insurance covers 100% of eligible costs.
What is a “referral” and who issues it?
A written authorization from a Primary Care Physician (PCP) allowing specialist visits.
This plan combines HMO and PPO features.
POS (Point of Service) Plan
In Standard COB, how does the secondary plan pay?
It pays the remaining balance after the primary plan.
What does “INN” and “OON” stand for?
In-Network and Out-of-Network.
What’s the difference between Medicare and Medicaid?
Medicare: Federal, for seniors/disabilities; Medicaid: State + Federal, for low-income individuals.
In this plan, the employer pays healthcare claims directly instead of premiums.
Self-Funded or Self-Insured Plan
In Non-Duplication COB, when does the secondary plan pay nothing?
When the primary pays more than what the secondary would have paid.
If Deductible = ₹1,000 and Coinsurance = 20%, how much does a patient pay for a ₹10,000 bill?
₹2,800 (₹1,000 + ₹1,800)
What’s the difference between a Calendar Year and Benefit Year?
Calendar Year renews in January; Benefit Year renews on a specified month.
In this plan, the employer pays a fixed premium, and the insurance company handles all claims.
Fully Insured Plan
In a Dual Complete Plan, which plan is primary?
Medicare Advantage
What are the basic deductible and OOP rules for individuals and families?
Individual ≤ Family, Max ≥ Met, and Out-of-Network costs are higher.