Birthday Rule– a set of guidelines that the health insurance industry has widely adopted for the coordination of benefits when children are listed as dependents on both parents’ group health plans. It applies specifically to dependent children with dual coverage and does not apply to adults. Under the birthday rule, the health plan of the parent whose birthday comes first in the calendar year is designated as the primary plan. It doesn’t matter which parent is older – the year of birth isn’t a factor. The primary plan pays first, and the secondary plan pays the remaining balance up to the total allowed charge. An exception to this rule is if one parent is court ordered to hold “primary” coverage on the child(ren).
Coinsurance– The amount shared by you and your plan for health costs, calculated as a percentage. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. You can always pay ahead at the time of service in full or partial towards coinsurance amounts. Just let the Front Desk know how much you would like to apply to the visit at the time of Check-in.
Coordination of Benefits (COB)– Coordination of Benefits is the process by which insurance companies determine how to cover medical expenses when a person is covered by more than one health insurance plan. This is often required to be updated yearly and can usually be completed online or by calling the Member Services phone number on your insurance card. Your insurance carrier may suspend claim payment pending yearly COB update requests. If you or your child have a claim denied for COB you will receive an EOB from your insurance carrier, a statement, and usually a call or text from Peacock. Recommended steps for COB completion when claims are denied are as follows:
- Contact Member Services
- Update COB for all members on the insurance policy
- Request all previously denied or suspended claims be reprocessed
- Obtain Representative name and call reference number
- Provide Peacock with the update information from your call with insurance
- Peacock will set balances back to Insurance Responsibility and follow up with insurance as needed
Copayment– More commonly referred to as a copay, this is a set amount you’ll pay for covered health services once you’ve met your deductible. Copays can vary depending on whether it’s for a medication, a visit to the doctor, or a lab test. If your insurance plan states that your copay for visits to the doctor is $20, that’s how much you’ll pay for that care.
Deductible– The amount of health costs you are responsible for before the plan starts sharing costs. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. After that, you’ll typically only pay a copay and/or coinsurance for covered care. The deductible may not apply to all services. You can always pay ahead at the time of service in full or partial towards deductible amounts. Just let the Front Desk know how much you would like to apply to the visit at the time of Check-in.
Dual Coverage– a situation where a person is covered by more than one health insurance policy. This can happen when an employee can receive benefits through their own plan as well as their spouse’s or parent’s plan. Dual coverage can provide more extensive benefits and reduce out-of-pocket costs for medical care. However, the two carriers will coordinate the payments so that the total amount paid does not exceed the total allowed charge. If the patient has Medicaid, they will always be billed last.
Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)– These health services are available for children under age 21 enrolled in Medicaid. EPSDT provides screening, vision, dental, hearing, and other necessary healthcare services.
Explanation of Benefits (EOB)– This is a document you receive from your health plan after using your medical insurance. It breaks down how much you and your health plan are each responsible for paying. An EOB is not a bill. It gives you a heads-up about what to expect when the actual bill arrives from your healthcare provider. It includes payment details, benefits, discounts, and denial reasons.
Family and Medical Leave Act (FMLA)– This law provides eligible employees with up to 12 weeks (about 3 months) off work in a 12-month period without pay. FMLA applies to a leave for specific family or medical reasons, and you can still use your employer’s health plan.
Flexible spending account (FSA)– A health care account that lets you put money aside, tax-free, to spend within the plan year to help pay for medical costs, childcare, and other health services.
Health Maintenance Organization (HMO)– An HMO stands for “health maintenance organization” and is a type of health insurance plan. HMOs work with specific doctors and hospitals to be part of their network of medical providers. These plans typically don’t cover any care from a provider outside of their network, except in the case of emergencies.
High-deductible health plan (HDHP)– High Deductible Health (HDHP) plans, a type of Consumer Directed Health Plan (CDHP) or Consumer Health Plan (CHP), are becoming increasingly popular for those who don’t need to see the doctor very often. These plans may behave like an HMO or PPO plan but have much higher deductibles to meet in exchange for lower monthly premiums.
Health reimbursement account (HRA)– A health care account that employers fund for covered workers or retired persons to pay for health care expenses.
Health savings account (HSA)– A bank account that lets you put money aside, tax-free, to save and pay for health care expenses. Any remaining money at the end of the plan year is yours to keep.
Medicaid– Medicaid provides free or low-cost health insurance to certain groups including low-income families and children, pregnant women, adults over the age of 65, and people with disabilities. The federal government provides a portion of the funding and creates guidelines, rules, and restrictions. Medicaid programs and what they’re called may vary from state to state.
Medicaid Managed Care Organizations (MCO)– Missouri Medicaid agency contracts with three MCOs: Healthy Blue, UnitedHealthcare, Home State Health. All providers at Peacock are in network with all MISSOURI Medicaid MCOs. We are not contacted with any Kansas Medicaid plans. All Kansas Medicaid patients will be considered Self-Pay for all services provided at Peacock. The MCOs provide quality care to Medicaid participants while following the Missouri HealthNet program’s guiding principles.
Network– The health care providers (facilities, doctors, specialists and suppliers) your health insurer or plan has contracted with to provide health care services.
Out-of-network (OON)– The health care providers (facilities, doctors, specialists and suppliers) that are not contracted with your health insurer or plan to provide health care services.
Out-of-pocket limit (or Maximum) (OOPL)- The total amount of health costs you are responsible for before your plan pays 100% of covered health costs for the rest of the year. Every health plan has its own out-of-pocket maximums.
Point-of-Service plan (POS)– A POS is a managed-care health plan that offers lower costs when you use in-network providers. Like an HMO, you must have a primary doctor. And a referral is required to see a specialist. This plan does give you the flexibility to use out-of-network providers. But it will cost you more. Also, with a POS, you will likely have copayments but no deductible.
Pre-Authorization (PA)– A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.
Preferred Provider Organization (PPO)– A preferred provider organization (PPO) is a type of health insurance plan. PPOs have a network of participating providers that you’ll pay less to visit. You can visit facilities, doctors, and providers outside of the network for a slightly higher cost.
Premium– The amount you pay for a health insurance plan that is deducted from your employee paychecks.
Preventive Care– Preventive care refers to routine health care services meant to prevent sickness, disease, and other health-related issues from developing. Although health insurance policies may offer varying degrees of preventative care services, the Patient Protection and Affordable Care Act (ACA) of 2010 requires insurance plans to cover certain ones at no cost to the policyholder. Ideally, these check-ups, counseling, screenings, immunizations and more help the body maintain its health and reduce its vulnerability to disease and injuries and the need for urgent or emergency services. **There are exceptions to EVERY rule** Some “grandfathered health plans” and most “Short Term plans” do not cover any Preventive Care and/or immunizations or have very strict limitations. These exceptions can leave large, sometimes unexpected balances for patients. It is extremely important to know and understand your Preventive Care benefits before scheduling Wellness Visits and Immunizations for yourself and your children. Peacock Pediatrics can assist both un-insured and under-insured patients with cost saving options for Preventive Care and immunizations.
Primary Care Provider (PCP)– Routine health care, including screenings, check-ups and patient counseling to prevent or discover illness, disease or other health problems. Dr. Cebulko, Dr. Williams, Dr. Ford, Dana Kapp and Sarah Sass are all PCPs.
Referral– A written order from your primary care provider for you to see a specialist or get certain health care services.
Self-Pay– Any uninsured patient, or patient with out of network insurance that Peacock cannot bill. Examples include but are not limited to Ambetter and Kansas Medicaid. Peacock offers flexible payment options if needed.
Underinsured– Someone who has health benefits that don’t adequately cover their medical expenses. This may include high deductibles, limited or non-covered Preventive Care and immunizations, or other out-of-pocket costs.
Uninsured– You have no medical insurance coverage at all.