Plan Year

The plan year refers to the12 month’s period starting when coverage under the Insurance Plan becomes effective for participants and their eligible dependents. After the 12 months have elapsed, the participants are allowed to renew the contract for them to continue receiving the benefits.

PPO

The plan is a PPO, i.e. Preferred Provider Organization. By definition, a PPO is a managed care insurance plan that gives the participant a moderate amount of freedom to choose their healthcare providers. Under the PPO plan, the insurance company has a list of preferred healthcare providers, often referred to in-network physician or healthcare provider, where the participants and their eligible dependents can choose to obtain healthcare services. Any participant seeking services from the in-network healthcare providers pay less and have less paperwork. By the fact that the insurance plan has a network of healthcare providers such as the dentists that they encourage the participants to seek medical services from, while at the same giving them the freedom to choose other healthcare providers if need be qualifies for the plan as a PPO plan. This information is availed in the company’s insurance benefits booklet.

Co-Pay

The plan provider allows for the participants to pay out of pocket a specific fixed amount after receiving a particular health care service. This amount is referred to as co-pay or a co-payment. The insurance company then settles the other payment. Huge co-pay reduces the utilization and influence of medication compliance. For instance, if I have no enough amounts to trigger my co-pay, then I might be forced to forego a particular medication.

Deductible

A deductible refers to the amount of money in the insurance claim that an insurance policyholder would have to pay before the insurance coverage kicks in and the insurance company starts paying. In simple terms, it is amount to be deducted from the amount otherwise payable as Covered Medical Expenses before payment of any Benefit is made. In the case of the Saudi Arabian Cultural Mission student health plan, the deductible amount for preferred providers is $0 per covered person per policy year. For out of network providers, the deductible amount is $10,000 per covered person per plan year.

Co-Insurance

The coinsurance applies in the coverage where the insurance company pays a percentage of Covered Medical Expenses. What happens is that the insurance company and the insurance policy holder share a medical cost after the deductible, say a 20%/80% share ratio. The coinsurance and the co-pay are two different concepts in the sense that the co-pay is a flat fixed amount while a coinsurance is a percentage of the cost. For co-pay, the insurance policyholder has to pay a specific set amount that is agreed upon with the insurance company to access some medical services. In the case of a coinsurance, the cost is shared as and expressed as a percentage.

As the terms of the policy dictates, a policyholder is required to identify a Primary Care Provider (PCP) upon signing the insurance coverage contract. The PCP, in this case, is the clinician who provides integrated, accessible health care services and who is accountable for addressing a vast majority of personal health care needs for the participant. However, by the fact that the insurance plan has a list of preferred healthcare providers, it means that the participants do not necessarily have to use the PCP. They can choose any of the listed preferred healthcare providers. They also have the freedom to choose other out network healthcare providers to access medical services.

The coverage requires all the policyholders to notify the administrators of all hospital confinements before admission. As provided in the coverage policy, all outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies require pre-certification. Invade of medical non-emergency hospitalization; the coverage needs the patient to reach out to the company at least five working days before the planned admission. In case of emergency hospitalizing, the patient, the patient representative or the PCP should notify the company within two days of the hospitalization. Failure to follow these requirements affects the plan benefits. For instance, the insurance policyholder may be required to pay more of the medical cost from the pocket, or the insurance company may not pay for medical cost at all. This means that as, a patient who is a policyholder, one has to fulfill all the obligations of the coverage even if the conditions are not favorable.

In an insurance policy, a formulary refers to a drug list with a list of medications updated continually. The formulary covers all categories of medication that patients require. The reason for continually updating and revising the list is to make sure patients when necessary receive the appropriate medication. This coverage, just like many more has the formulary service that is used to encourage the use of safe, effective and most affordable medications.

Indeed, the insurance plan does cater for wellness benefits of the participants. Through preventive care services such as weight management program and lifestyle management program, patients can live an active life without stress. They also provide annual check-ups, as well as most immunizations and screenings. These wellness benefits help the participants to stay healthy all through and reduce the chances of falling sick.

Out-of-Network

An out of network stipulation means that an insurance company has the provision of allowing a patient not contracted by the insurance company for reimbursement at a negotiated rate. In this regard, healthcare providers or physicians not contracted by the insurance company are considered out of network. This stipulation does in an exceptional way impact patient access to healthcare in that if the patient contracts the out of network physicians or healthcare providers, they are forced to pay more.

References

Andersen, M. S., Buttorff, C., & Alexander, G. C. (2016). Impact of HIE Drug Formularies on    Patient Out-of-Pocket Costs. American Journal of Pharmacy Benefits, 8(6), 220-+.

Nobles, A. L., Curtis, B. A., Ngo, D. A., Vardell, E., & Holstege, C. P. (2018). Health insurance literacy: A mixed methods study of college students. Journal of American College Health,     1-10.

Uberoi, N., Finegold, K., & Gee, E. (2016). Health insurance coverage and the Affordable Care   Act, 2010-2016. Washington (DC): Department of Health and Human Services, Office of   the Assistant Secretary for Planning and Evaluation.

 
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