Lesson 1, Topic 3
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Key Terminologies

Master August 6, 2020
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  1. Insurance Plan
    This an Insurance Policy designed and offered by the HMO to cover a specified type of healthcare services for specified type of Beneficiaries e.g. Senior Citizens, Students, etc
  2. Insurance Premium
    This is the amount specified by the HMO for each Insurance Plan and Cover Period, to be paid periodically (e.g. annually) by the Beneficiary to be covered for the stipulated Cover Period
  3. Minimum Instalment
    This is the amount stipulated by the HMO as the minimum payable by the Beneficiary each time a part-payment is made, where instalment payments are allowed by the HMO
  4. Cover Period
    This is the period of time stipulated as premium and service coverage cycle by the HMO. It is usually a one-year cycle

5. Cover Limit
This is the maximum amount of healthcare expenses stipulated for each Insurance Plan, that the HMO has assured to cover and pay for each Beneficiary within each Cover Period e.g. pay premium of N108,000.00 ($300) and get covered to the tune of N2.5 million ($5,000) over 1 year period

6. Waiting Period
This is the period of time stipulated by the HMO for each Insurance Plan during which a Beneficiary cannot start accessing the healthcare services after paying the stipulated premium amount.

It is usually counted as days or weeks from the date the full payment of the stipulated premium amount is made

7. Plan Cover
This is the general, non-exhaustive list and types of healthcare services that can be accessed under each Insurance Plan

  1. Excluded Services
    These are the list and types of healthcare services that cannot be accessed under each Insurance Plan
  2. Partial Exclusion
    This is the list and types of healthcare services that can be partially accessed under each Insurance Plan, subject to certain stipulated terms and conditions
  3. Limited Exclusion
    This is the list and types of healthcare services that can be accessed under each Insurance Plan, subject to certain stipulated terms and conditions such as frequency and amount

11. Claims
These are Beneficiaries’ healthcare expense bills submitted by Hospitals to the HMO for payment / reimbursement