Affordable Care Act
Also called ACA or Obamacare, the ACA is the 2010 health care reform act aimed at expanding health insurance coverage to more Americans. The ACA requires some businesses to offer health benefits or face heavy fines. As of 2019 the Individual mandate, which penalized individuals for not maintaining health insurance coverage, no longer applies at the federal level. However, 5 states and the District of Columbia have an individual mandate at the state level.
Claims
A request by an insured person, or a health care provider of an insured person, for the insurance company to pay for services. Claims are processed by the carrier or TPA.
Exclusions
Medical expenses that are not covered by your plan. This can be certain providers, types of treatments or procedures, and medications. Exclusions vary by plan, so we work with you to find the best one for your company’s needs.
Fully-Insured Plan
Traditional health insurance plans in which an employer pays a premium to a carrier to cover the cost of the employees’ healthcare.
Guaranteed Issue
Insurance policies that do not require underwriting. Prices for these plans are fixed according to age and/or tobacco status.
Insurance Agency
A company authorized by carriers to sell the insurer’s products. Agencies and agents are regulated by each state they operate in. Membership.com is a licensed agency in all states except California.
Insurance Carrier: A company that provides insurance coverage. Employers pay monthly fees to carriers to pay claims and administer benefits.
Level-funding
Level funding is a way to pay for a self-insured plan that allows for fixed monthly payments and minimizes the risk of high claims.
Providers
Licensed professionals who provide health care services. Providers include medical doctors, dentists, optometrists, and clinical psychologists, as well as some other providers of health care.
Self-Insured Plan
An employer health plan where the employer pays for employee’s medical claims rather than paying a premium to a carrier. Most small and medium-sized companies pay for self-insured plans using level funding payment plans. Plans on Membership.com are self-insured and governed under the Employee Retirement Income Security Act (ERISA).
Stop-Loss Insurance
A type of insurance that protects against high claims. If claims exceed what was expected, stop-loss kicks in to pay the excess so that you never pay more than your fixed monthly payment.
Third-Party Administrator
Also known as a plan administrator, a TPA helps secure, administer, and manage a group’s benefits plan. Membership.com is not a TPA, but we do work with TPA’s to ensure the best service to each employer.
Underwriting
The process of evaluating a group’s application for health coverage. Underwriters look at your group’s health and risk factors to determine whether or not coverage be offered and at what price.