Vision Insurance Definitions You Need to Know

Without knowing the meaning of the different terms found in health insurance terminology, reading the definitions for vision care insurance can be confusing. In this article we will explain some of the terms found in vision and eye care pamphlets that you need to know.

The calendar year always pertains to a 12 month cycle that begins January 1 and ends December 31.
Most plans have placed a set dollar limit which is defined as the “Capitation” regardless of how much or how little you use of the predetermined amount. This is what the provider pays for services rendered in a single calendar year.

The Carrier is defined as the HMO or the insurance company who offers the health plan.

Co-insurance is the amount “you” the insured pays after your deductible has been met. Usually your co-insurance is a percentage of that deduction. For example, 80 percent of the fee for medical services is paid for by your employer or insurance company, and the remaining 20 percent is your responsibility. Most plans have yearly deductible amounts as terms of the coverage.

A “Defined Contribution Plan” is when the employee contributes a certain portion of money each calendar year into his own personal employee account which is set aside to pay for medical expenses.
If an insurance company decides not to pay for medical care requested from the provider this is a “Denial (of the claim.)

Spouses and/or children of an insured person are defined as “Dependents”.

Any eye care services that are not covered under the vision called “Exclusions”.

FSH is an abbreviation for “flexible spending account” with provisions allowing an employee to use pre-tax dollars to purchase benefits which may not be covered in their plan such as vision or eye care benefits.
Generic Drugs are medications that are almost identical to brand name products. Once the patent on brand name medications has expired the generic makers of the same drug can market their products more competitively. Typically the generic drug is much cheaper and your health care provider will recommend you choose the generic over the name brand.

Vision insurance which is purchased by organizations like unions or businesses is known as “Group Vision Insurance” providing coverage for all individuals employed.

“HIPPA” is a federal law implemented in 1996, “The Health Insurance Portability and Accountability Act”, this law protects the privacy of medical records and places limits on sharing personal identifiable information. HIPPA allows you the insured to qualify for immediate and comparable coverage should there be a change in your employment status. Your eye doctor will provide you with documentation which should be signed to verify you are covered by the HIPAA guidelines.

HMO stands for “Health Maintenance Organization”. They provide pre-paid insurance plans where an individual or employee pays a fixed monthly fee for all services rendered instead of separately paying for each visit or service. Regardless of the level of service the monthly capitation always stays the same.
Health Savings Account (HSA) is a savings account set up in advance which is used to pay for health care and eye care with pre-tax income. You must have a high-deductible health insurance policy in order to open a HSA type account.

Individual Vision Insurance Eye Care Coverage is coverage sold to an individual instead of a group. Generally your membership fee will be a little higher.

IPA’s are an “Independent Practice Association” consisting of eye and/or health care providers. They are similar to HMO’s with the exception that you are seen in a private doctor’s office instead of an HMO facility.
Managed Vision Care is a management company that oversees the quality and cost of eye care services. Typically it is provided by an HMO or a preferred provider organization which includes independent eye doctors.

Membership Fees are your annual fees which keep your vision plan current.

Networks include individuals consisting of hospitals, doctors and health care providers agreeing to provide services for less than the usual fee.

Out Of Network In Vision Care are ophthalmologists and optometrists that do not provide for eye care services at discounted rates.

Outpatient Services are services provided that do not include overnight stays in hospital or medical facilities which may include LASIK and cataract surgery. Be sure to read your coverage carefully as many insurance companies will not cover the cost of certain tests or procedures unless performed on an outpatient basis.

PPOs are “Preferred Provider Organizations. These health care providers are established by an insurance company that provides health care for policyholders at discounted rates. If you choose a PPO your coverage will be at a higher cost.

Premiums are the annual fee you pay each year to keep your coverage current.

Primary Care Provider is the ophthalmologist or optometrist that monitors your individual eye care. They perform routine annual examinations and refer you to specialized doctors for additional care.

The Provider is the health care physician which provides services to the patient. Providers generally accept most plans. Upon your first visit they will review your plan to determine if the eye care insurance presented is acceptable.

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