Insurance Basics

Introduction

What You Need to Now that you work for an insurance company, many people may approach to ask your opinion on insurance. Maybe they don't understand how a
Know deductible works, or what the word product means. Perhaps they could benefit from just general knowledge of insurance.

This module provides a foundation to add to your understanding of what insurance is and how it is organized.
Before long, you will be impressing your friends and neighbors about your knowledge of what insurance is and how it helps people!

Objectives After completing this training, you will be able to:

1. Define insurance and the different insurance types available.

2. Define insurance related terms and acronyms.

3. Use available resources to research unfamiliar terms.

      
Overview This module provides a high-level view of insurance.  We are focusing on insurance types, acronyms and terms and plan variations. 

What is Insurance?
Insurance

Definition Insurance is a system designated to protect individuals or groups of individuals against unforeseen illness, injury, death, or other losses in return
for premiums paid.  

The intent is to distribute the losses incurred by a few unfortunate individuals among a large number of individuals who may be exposed to the
same or similar risk.  
 Very simply, insurance provides financial protection against different types of losses. This protection is called coverage.

Insurance Types The following table lists different types of insurance and their descriptions.

Type of Loss (Insurance) Description

Life Insurance
Vision Insurance
Dental Insurance
Disability Insurance
Health or Medical
Insurance
Protects the beneficiaries of the insured in the event of the insured’s death.
Protects the insured from losses incurred due to routine eye care.
Protects the insured from losses incurred due to routine dental care or dental care not covered under health
insurance.
Protects the income of the insured when unable to work
Protects the insured from losses due to illness, injury or pregnancy.

Group vs. Individual Insurance

Individual Insurance A personal policy designed to protect the individual and dependents.  

Individual is also known as the policyholder.  

Policyholder must show evidence of good health.  This is called Insurability.  

The consumer pays the premium.

  
Group Insurance Designed to provide protection (coverage) to a specific group of people under a single insurance contract.      

The employer is the policyholder.

The premium contribution is shared between the employer and the employees (usually the employer is the major contributor).  
 Evidence of insurability is usually not required.

Advantages of Group Two advantages of group insurance are:

Insurance
 Lower cost - Premium costs are shared between the employee and the employer.

 Waived Insurability – Unlike an individual policy, evidence of good health is not usually required.

Medicaid               

Definition Medicaid is a state sponsored health welfare benefits program provided to individuals of limited or no income who are not eligible for Medicare,
and individuals under the age of 21.

Payment Instead of paying the actual provider of service, the group health carrier is required to pay Medicaid directly.  The payees will either be the
Medicaid State Agency, or a vendor used by the state to recover these dollars.

Medicaid and its vendor agencies have tax identification numbers just like the actual providers of service.  This allows us to build their address in
our system and make payment directly to the State or the vendor.

Review

Instructions Match the description in Column B to the item it describes in Column A.

 
   Colum A   Colum B
J Vision Insurance A An Individual Policy requires the Policyholder to show evidence of good health this is called...
  .

D Employer B Pays the premium for an Individual Insurance policy.

F Health or Medical C The premium contribution is shared between the employer and the employees (usually the employer is the major contributor).
Insurance

G Disability Insurance D The Policyholder of the Group Insurance policy.

K Personal Policy E State sponsored health welfare benefits program provided to individuals of limited or no income who are not eligible for
Medicare, and individuals under the age of 21.

C Group Policy F Protects the insured from losses due to illness, injury or pregnancy.

A Insurability G Protects the income of the insured when unable to work.

H Dental Insurance H Protects the insured from losses incurred due to routine dental care or dental care not covered under health insurance.

I Life Insurance I Protects the beneficiaries of the insured in the event of the insured’s death.

E Medicaid J Protects the insured from losses incurred due to routine eye care.

B Consumer K Designed to protect the individual and dependents.

 Acronyms and Terms
Acronyms

Section Objectives Upon completion of this section you will be able to:

 Identify basic acronyms and terms

 Describe how to locate acronyms and terms in myCoach.

Definition An acronym is a word formed from the first letters of a name or series of words.  For example, OOP is an acronym for Out of Pocket.

Acronyms Job Aid Click the link to view the Acronyms Job Aid.

Take a few minutes now to review the acronyms, terms and definitions in these two aids.  Some of them may be familiar, some may be brand new.

Use the Notes Area of your module as needed.

Leave this aid open for use in the next section.

Story of Confusion Activity

Notes Area Use scrap paper or the Notes Area to make a list of acronyms you hear during the Story of Confusion. 

Note:  Not all of the acronyms used will appear in your aids. 

Paragraph 1  
ATV All Terrain Vehicle
MRI Magnetic Resonance Imaging
SSN Social Security Number
DOB Date of Birth
COB Coordination of Benefits
RN Registered Nurse
Paragraph 2  
UHC UnitedHealthcare
PPO Preferred Physician Organization
ID Identification
IVR Interactive Voice Response
Paragraph 3  
CSP Customer Service Professional
ST Student
CSP Customer Service Professional
MIT Massachusetts Institute of Technology
ST Student
Paragraph 4  
CSP Customer Service Professional
 ISET Integrated Service Experience Tool
iBAAG Intranet Benefits at a Glance
EBDS Employee Benefits Data Summary
iBAAG Intranet Benefits at a Glance
CSP Customer Service Professional
ST Student
Paragraph 5  
CSP Customer Service Professional
RMO Regional Mail Operations
COSMOS         Comprehensive Online Software for
Management and Operational Support
EOB Explanation of Benefits
PDQ Pretty Darn Quick
OOP Out-of-Pocket
Paragraph 6  
ISET Integrated Service Experience Tool
CSP Customer Service Professional
CSPs Customer Service Professionals
UHC UnitedHealthcare
CSP Customer Service Professional
Paragraph 7  
CSP Customer Service Professional
ISET Integrated Service Experience Tool
A- OK A Okay

Terms and Definitions

Frontier
Open an internet browser and find the Frontier icon.  

Follow the steps below to locate the Frontier Terminology Glossary.

Step Action
1.  Click on Corporate Departments.                                                                                                
2. Click on Corporate Communications.
3.  Under I need.....click on a glossary.

This glossary provides another resource of terms and definitions.  As training continues, you will be introduced to additional resources. 

Take a few minutes to review the terms.

Resources In a future module you will be introduced to a web-based tool called myCoach, which houses many kinds of resource documents such as:

 Decision Trees

 Job Aids

 Standard Operating Procedures (SOPs)

For now, click on the link to access the Provider Service Acronyms Terms and Definitions job aid. 

Take a few minutes to look at this job aid.  Keep this job aid open for use during the review activity.

Review
Instructions Using the job aids provided earlier to locate the terms below and provide the definition for each.

# Term Definition
1 Allowable Expense - The allowable expense is the amount we will consider after all non-covered
amounts have been subtracted. The allowable expense is then the basis for the deductible and
coinsurance calculation.

The allow able expense is the amount w e w ill consider after all non-covered

amounts have been subtracted. The allow able expense is then the basis

for the deductible and coinsurance calculation.

  
2 Benefits - Benefits refer to the health care coverage provided by the employer for employees who select
health care coverage. The benefits indicate what the health care plan will reimburse for services
rendered to employees and their covered dependents.
Benefits refer to the health care coverage provided by the employer for

employees w ho select health care coverage. The benefits indicate w hat the

health care plan w ill reimburse for services rendered to employees and

their covered dependents.

3 Carryover - Carryover is the ability, per the contract, to allow services that were applied to the deductible
and/or out-of-pocket maximum, during the last quarter of the calendar year (October through
December), to be applied to the next calendar year deductible and/or out-of-pocket maximums.
Carryover is the ability, per the contract, to allow services that w ere applied

to the deductible and/or out-of-pocket maximum, during the last quarter

of the calendar year (October through December), to be applied to the

next calendar year deductible and/or out-of-pocket maximums.

4 Coinsurance - Coinsurance is the portion of covered health care costs the covered person is financially
responsible for, usually according to a fixed percentage. Coinsurance is often applied, according to a
fixed percentage, after a deductible requirement is met.
Coinsurance is the portion of covered health care costs the covered person

is financially responsible for, usually according to a fixed percentage.

Coinsurance is often applied, according to a fixed percentage, after a

 deductible requirement is met.

5 Coordination of Benefits - COB is a contract provision that applies when a person is covered under more
than one group medical program. It requires that payment of benefits will be coordinated by all programs
to eliminate over-insurance or duplication of benefits. The primary plan pays first; the difference is paid
by the secondary plan.
COB is a contract provision that applies w hen a person is covered under

more than one group medical program. It requires that payment of benefits

w ill be coordinated by all programs to eliminate over-insurance or duplication

 
of benefits. The primary plan pays first; the difference is paid by the

secondary plan.

6 Deductible - DED is a portion of the benefits, under a policy, that the employee and dependents must
satisfy before any reimbursement occurs. This is called the individual deductible.

DED is a portion of the benefits, under a policy, that the employee and

dependents must satisfy before any reimbursement occurs. This is

called the individual deductible.

7 Deductible Carry-over credit - The portion of a calendar year deductible satisfied, which may be eligible
to count toward the next year's deductible.

The portion of a calendar year deductible satisfied, w hich may be

eligible to count tow ard the next year's deductible.

8 Medicaid - Medicaid is a federal program administered and operated individually by participating state
and territorial governments that provides medical benefits to eligible low-income people needing health
care. The program’s costs are shared by the federal and state governments.
Medicaid is a federal program administered and operated individually

by participating state and territorial governments that provides

medical benefits to eligible low -income people needing health care. The

program’s costs are shared by the federal and state governments.

9 Medicare - Medicare is a nationwide, federally-administered health insurance program that covers the
costs of hospitalization, medical care, and some related services for eligible people, principally
individual’s age 65 and older, and disabled individuals under age 65. Part A covers inpatient hospital
 and skilled nursing facility care, home health and hospice care. Part B covers physician services,Medicare is a nationw ide, federally-administered health insurance program
outpatient hospital services, clinic services, lab services, and durable medical equipment.

that covers the costs of hospitalization, medical care, and some related

services for eligible people, principally individual’s age 65 and older,

and disabled individuals under age 65. Part A covers inpatient hospital

and skilled nursing facility care, home health and hospice care. Part B

covers physician services, outpatient hospital services, clinic services,

lab services, and durable medical equipment.

1 Network Provider - A network provider is a physician or other health care provider who has contracted
0 with the health plan to deliver medical services at contracted rates to covered persons. The provider
may be a physician, hospital, pharmacy, other facility or other health care provider who has contractually
accepted the terms and conditions (e.g., credentialing requirements) set forth by the health plan. Also
A netw ork provider is a physician or other health care provider w ho
referred to as a participating provider.)
has contracted w ith the health plan to deliver medical services at

contracted rates to covered persons. The provider may be a physician,

hospital, pharmacy, other facility or other health care provider w ho

has contractually accepted the terms and conditions (e.g., credentialing

requirements) set forth by the health plan. Also referred to as a

participating provider.

1 Out of Pocket (OOP) - OOP is the portion of payments for covered health services required to be paid
1 by the enrollee, including co-payments, coinsurance, and deductibles. The OOP maximum is the
maximum amount of copayments, coinsurance, and deductibles that the enrollee will have to pay each
calendar year. Once the out-of-pocket maximum has been met, the plan will pay 100% of covered
OOP is the portion of payments for covered health services required to
medical expenses.
be paid by the enrollee, including co-payments, coinsurance, and

deductibles. The OOP maximum is the maximum amount of copayments,

 coinsurance, and deductibles that the enrollee w ill have to pay each

calendar year. Once the out-of-pocket maximum has been met, the plan

w ill pay 100% of covered medical expenses.

1 Policyholder - This is the company, association, or group of employers that select us to administer their
2 plan benefits.

This is the company, association, or group of employers that select us to

administer their plan benefits.

Stop Wait for your facilitator to review the answers with you.

Jungle Jargon

Step Action
1 Print the Jargon Jungle header on a color printer or write the name in colorful letters.
2 Decorate the poster with jungle items (flowers, parrots, etc) – optional.
3 Insert names of local personnel, such as:

 Supervisor

 Manager

 Training Manager

 Site Director

 Quality Assurance representative

  Workforce representative

Note:  this allows the participants to associate names and positions will people with whom they will be interacting over the next several
weeks and years.
4 Use 3x5 Post-it Notes to write new acronyms and terms and place them on the poster.
5 Throughout training allow you - or the participants – will write any new acronyms or terms on the 3x5 Post-it and place it on the chart.
6 Beginning each day challenge the participants to review the previous day’s words of the poster as they come in for the morning.

Result:  This will help wake them up, trigger brain functions, and prepare them for new input through out the day.
7 After lunch, at the end of the day, or the next morning, add the next set of terms to the board.
8 Continue adding, reviewing with the class, and encouraging self-review through out the first half of  training.

Welcome to the Jungle Jargon Jungle is another tool to help you with terms, definitions and even names. 

Summary

Objectives Now that you have completed this module you can:

1. Define insurance and the different insurance types available.

2. Define insurance related terms and acronyms.

3. Use available resources to research unfamiliar terms.