Answers to the Most Frequently Asked Employee Benefit Questions

Confused about common health insurance benefits terms? These FAQs cover the basics to take the mystery out of coverage terms!

What is a Deductible?

A deductible is the amount of money you or your dependents must pay toward a health claim before your organization’s health plan makes any payments for health care services rendered. For example, a plan participant with a $100 deductible would be required to pay the first $100, in total, of any claims during a plan year.

What is Coinsurance?

Coinsurance is a provision in your health plan that describes the percentage of a medical bill that you must pay and that which the health plan must pay.

What is Out-Of-Pocket Maximum?

The maximum amount (deductible and coinsurance) that you will have to pay for covered expenses under a plan. Once the out-of-pocket maximum is reached the plan will cover eligible expenses at 100 percent.

What is an Explanation of Benefits (EOB)?

An EOB is a description your insurance carrier sends to you explaining the health care benefits that you received and the services for which your health care provider has requested payment.

What is a Pre-Existing Condition?

A pre-existing condition is a physical or mental condition that existed prior to being covered on a health benefit plan. Some insurance policies and health plans exclude coverage for pre-existing conditions. For example, your health plan may not pay for treatment related to a pre-existing condition for one year. You should check with your insurance carrier to learn how your organization’s health plan treats pre-existing conditions.

What is a Preferred Provider Organization (PPO)?

A PPO is a group of hospitals and physicians that contract on a fee-for-service basis with insurance companies to provide comprehensive medical service. If you have a PPO, your out-of-pocket costs may be lower than in a non-PPO plan.

What is Utilization Management?

Utilization Management (UM) is the process of reviewing the appropriateness and the quality of care provided to patients. UM may occur before (pre-certification), during (concurrent) or after (retrospective) medical services are rendered.

For example, your health plan may require you to seek prior authorization from your utilization management company before admitting you to a hospital for non- emergency care. This would be an example of pre-certification. Your medical care provider and a medical professional at the UM company will discuss what is the best course of treatment for you before care is delivered. UM can reduce unnecessary hospitalizations, treatment and costs.


Managed Care: Health Insurance Terminology

What is Health maintenance organization (HMO)? Or how about Preferred provider organization (PPO)? This article defines managed care and several other terms related to medical insurance.


Frequently Asked Questions about HSA Plan Usage

How do I manage my HSA? What expenses are eligible for reimbursement from my HSA? Can the funds in an HSA be invested? Find out the answers to these health saving account questions and more about.


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Let us help you find solutions to the challenges your business faces today and tomorrow. Whether your looking to protect your family, home, auto, or business, at Montgomery & Graham Inc we have got you covered. Our team has worked with businesses of all sizes, and individuals with unique circumstances to provide Washington & Oregon health insurance they can trust.

Schedule a consultation to find out how you can take control of your health insurance cost and offer employee benefit packages that excel in company wellness and employee retention. Understand your options and know about the latest insurance strategies, and save money offering innovative healthcare and risk management solutions. We solve problems at M&G, contact us today!

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M&G Benefits resources offer you the lastest in insurance and health care complaincy. Stay up to date on the need to know news regarding employee benefits.Insurance Industry Briefs

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As an employer, you want employees to understand and appreciate the substantial value of their benefits. It is important that employees understand their benefits when they are enrolling to ensure they make the best choice for themselves, their family, their lifestyle and their budget.


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All group medical benefit plans fall into one of two categories: self-funded or fully insured. This article explains the differences between self-funded and fully insured employee medical benefits.