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ClaimLinx Glossary: Common Health Insurance Terms

ClaimLinx specializes in many health insurance services, including traditional group health insurance, employer-paid benefits, employer benefits consulting, supplemental insurance, and individual plan consulting. We’re a full-service insurance agency. Our team works to lower your health insurance costs while giving employees their ideal health insurance plan. In today’s blog, ClaimLinx explains common terms you might encounter as you are reviewing our services for health insurance plans.

Premium

A premium is the amount an individual pays for health insurance every month. Some employer-paid benefits come at no cost to employees, while others have employees pay premiums at a lower cost. For example, an employer could pay $100 a month for a worker’s health insurance while the employee pays $75 per month for the rest. ClaimLinx finds the right balance between premiums and out-of-pocket expenses for health care when it comes to employees.

Deductible

A deductible represents the amount someone pays for health care services, such as a doctor’s office visit or a trip to urgent care before the health insurance plan pays for part of the rest. For example, an employee’s deductible could be $500. After the person pays $500 for services, insurance may pay all or part of the rest of the health care services, thereby lowering someone’s overall healthcare costs the rest of the year. Our ClaimLinx Solution is a strategy that lowers the employer costs as well as the out-of-pocket costs of workers, saving everyone money.

Copayment (Co-Pay)

A copayment (commonly known as co-pay) is the fixed amount that someone pays for health services after the person pays the deductible in full. A visit to the doctor’s office may come to $100, but the copayment made by someone with health insurance lowers the cost to just $20 paid out-of-pocket. ClaimLinx determines optimal copayments for employees with respect to their deductibles.

Claim

When you file a claim, you request payment for healthcare services covered by a health insurance plan. As a third-party administrator, ClaimLinx offers easy ways for employees to file claims for processing so they can receive their benefits in a timely manner.

Marketplace

One service offered by ClaimLinx is the ability to let individual employees shop for their own personalized health insurance plan. This happens on a marketplace, sometimes called an exchange or health insurance marketplace, run by the state or federal government. A marketplace allows someone to put in their information through an online portal, and then the marketplace shows them the plans they are eligible for. 

ClaimLinx Experts Help You and Your Employees

Our expert health insurance consultants can help you and your employees wade through the jargon, options, and health insurance companies to find the best possible health coverage for everyone. Contact ClaimLinx or call our office at (800) 858-1772 to find out how we can save you between 20 and 40 percent on employer-paid benefits for your loyal workers.

Clogged emergency departments highlight need for alternative fees

Emergency departments were never meant for routine visits for people with chronic conditions, but in the absence of coordinated care, confused patients have turned to them when they don’t know where else to go.

Now, people with six common chronic conditions make up about 60 percent of all emergency room visits, according to a report released this year by Premier. Of those visits, about one third of them were likely preventable and accounted for $8.3 billion in additional costs for the industry.

This information came as no surprise to industry experts but highlights the need for the healthcare industry to rethink its service environment as a way of managing costs. Currently, about 90 percent of providers use a fee-for-service payment structure, which means that most people, especially those with chronic conditions, receive health services from a variety of providers with no single party coordinating care.

This style of care is not only confusing for patients but can also be dangerous and expensive. Fragmented care is associated with communication gaps, more hospital admissions, poorer outcomes and higher costs.

The problem only becomes worse for people with more than one chronic condition. Patients with one to two chronic conditions and highly fragmented care were 13 percent more likely to visit an emergency room and 14 percent more likely to require a hospital admission.

Fixing the issue would require a shift to a value-based model, in which a chronically ill patient receives care in a coordinate way that helps manage disease progress and promotes wellness. That way patients are guided through the management and/or treatment process rather than having to guess or piece together a picture of how ideal care would look.

“More and more providers are convinced that the future is going to be value-based payment, said Joe Damore, senior vice president of population health consulting at Premier, who produced the report.

The study looked at data from 24 million emergency department visits at 747 hospitals within Premier’s database.

Until the model changes, however, it’s important patients be their own advocates and consider the cost of an emergency room visits before going. Remember that managing a chronic condition is a learning process. There is no shame in asking questions.

We recommend to our members to ask their physicians as much as they can about what to do when a complication or issue arises. Try to remember that the emergency room was never meant to be a go-to first step in receiving care. They are set up for urgent visits when treatment is needed immediately. That can sometimes mean being proactive and aware of a provider’s regular hours.

Have a happy healthy summer with these tips

It’s officially summer. That means longer days, more sunshine and hopefully more time to enjoy friends, family and the outdoors. This year, start your summer off right with these quick tips for making the most of this sweet, sunny season.

Tips for enjoying the home – Use this summer to reclaim joy in your home and your town.

  • Rediscover your yard – Sometimes all the nature you need is right in your own backyard. Have dinner as a picnic, plan a Friday night camp out, or even rent or buy a projector for an open-air movie night.
  • Be a tourist in your town – All residents have places in their towns where they might go if they were a tourist, but have never gone as a local. Try a new restaurant, go to the town museum, finally make it out to the summer fair or festival. You might even find a new favorite place along the way.
  • Channel your inner child – Think back to when summer was full of endless possibilities and reclaim that feeling by bringing a little silliness into your life. Plan a trip to the local water or amusement park, go to the park up the street, mow a maze into your lawn or start a scavenger hunt around the neighborhood. Just make sure it’s something that makes you smile.

Tips for enjoying vacation – Family trips are fun, but they can also be stressful and exhausting.

  • Think small and more often – The temptation to make every trip “once in a lifetime” can be intoxicating, but big trips aren’t any more fun or memorable than smaller ones. For your next trip, take the pressure off by planning something easy to get to and less expensive. You might even be able to take more than one vacation that way.
  • Enjoy the planning phase – Anticipation of a trip can sometimes be just as fun as the trip itself: picturing yourself on vacation, reading up on new foods or activities, talking to others about what you want to do. Revel in this process as much as you can, it can only make the enjoyment of the trip more fun.
  • Manage your expectations – Try not to fantasize too much about your trip. You may need to work while you’re out, have a long drive ahead, need to corral children to different locations, do housework. Know these activities are in your future, accept it and focus on the joy that surrounds these less pleasurable activities.

No matter what’s in your future this summer, the best advice is always to try make the most of each moment. Take time for yourself, your friends and your family.

Trump administration tackles drug advertising

Coming this summer: another addition to the “fine print” on all those drug commercials. Under a new rule announced this month by the Trump administration, pharmaceutical companies will have to reveal how much their drug costs during TV commercials.

The rule is set to go into effect this summer and will require drug companies to include the price of a drug if it exceeds $35 for a 30-day supply, or the usual course of therapy.

The move is meant to increase transparency in the industry and ideally force pharmaceutical companies to lower its sticker prices on drugs for fear of appearing too expensive.

“Requiring the inclusion of drug list prices in TV ads is the single most significant step any administration has taken toward a simple commitment: American patients deserve to know the prices of the healthcare they receive,” said Alex Azar, Health and Human Services secretary.

As expected, drug companies pushed back on the new rule. Representatives said they fear including drug prices during commercials will discourage customers from asking their physicians about the drug because they believe they cannot afford it. The new rule stipulates listing the price before any discounts or health insurance coverage, which could lower the cost.

It is notable, however, that because of rising costs an increasing number of Americans are being forced onto high deductible health plans, which can often lack the comprehensive drug coverage required to significantly reduce the cost of prescriptions.

“If drug companies are ashamed of those prices—lower them,” President Donald Trump tweeted shortly after the rule was announced.

Industry experts do not necessarily oppose the new rule, but are skeptical it will result in substantial cost reductions, especially because enforcement of the law is left to the drug companies themselves.

If one drug company fails to include the pricing information in an ad, a competitor can file a lawsuit under the deceptive and unfair trade practice provisions of the Lanham Act. No additional oversight plan has been announced by the Trump administration.

The consensus among Americans appears to be that added transparency in the pharmaceutical industry may be helpful, but is no guarantee. According to a POLITICO/Harvard poll in the summer last year, 63 percent of Americans favored including price information in drug advertisements, but only 28 percent believed it would lower costs.

As for the ClaimLinx team, we don’t expect this to bring about big change in the industry. If it does, though, you can bet we will be ready to use it to our advantage to lower costs for members and clients.

ClaimLinx wants member feedback

We’re always looking for ways to improve our services for our members. To that end, we are asking our members to answer a few questions. The survey takes less than two minutes, but gives us a lot of insight about their priorities, how happy they are with their plan and allows us to plan for future improvements.

Anyone who completes the survey can be entered to win a $100 American Express gift card as well as ClaimLinx promotional items. So please fill it out as soon as possible.