CARD T188
Provider Network
The health professionals and facilities contracted with a health plan to provide care. For example, participating doctors, hospitals, and clinics.
How it works
A provider network consists of contracted clinicians, hospitals, and other providers. Network status can vary by plan and product, even within the same insurance company. A facility’s participation does not automatically establish every clinician’s participation. Verify the exact plan, provider, and service; emergency and surprise-billing protections can alter member cost sharing. [10] [11]
A physician accepts one insurer’s PPO network but not its HMO network. The insurer’s name alone is insufficient to confirm participation.
Accepting an insurer generally is not the same as being in the member’s specific network.
CARD T189
Group Insurance
Insurance covering eligible members of a group under one master policy, often offered through an employer to employees or through an association to its members.
How it works
Group insurance covers eligible people through a master policy or group arrangement, commonly tied to employment or association membership. The sponsor may pay all or part of premiums. Eligibility, enrollment windows, and dependent rules matter. Group health and group life have different continuation and conversion rules; neither should be inferred from the word group alone. [10] [11] [17]
An employer holds a master policy covering eligible employees, while each covered employee receives evidence describing individual coverage.
The master policyholder and each insured member are different roles.
CARD T190
Certificate of Coverage
A document explaining an individual member’s coverage under a group policy. For example, an employee receives a certificate describing coverage under the employer’s master policy.
How it works
A certificate describes a covered person’s benefits and relevant conditions under a group policy. The sponsor generally holds the master policy. A certificate is evidence of coverage, not a guarantee that every service or loss will be paid. It should be read with the governing policy and required notices; discrepancies require resolution under applicable law. [10] [11] [17]
An employee uses the certificate to review covered benefits, exclusions, and claim requirements under an employer’s group insurance.
A certificate does not make the employee the owner of the entire master policy.
CARD T191
Major Medical Insurance
Coverage for a broad range of significant medical expenses, subject to plan terms. It commonly uses deductibles and other cost sharing.
How it works
Major medical provides broad coverage for covered medical expenses rather than a small fixed payment for one event. Plans commonly use networks, deductibles, copays, and coinsurance. ACA-compliant individual and small-group plans include essential health benefits, including hospitalization, prescriptions, preventive care, and mental health services. A hospital indemnity or specified-disease policy is not a substitute for broad major medical coverage. [10] [11]
A broad plan shares covered hospital and physician costs; a hospital indemnity policy instead may pay a stated dollar amount per covered day.
Broad expense coverage and fixed-dollar supplemental benefits are different products.
APPLY THE TERMS
Practice questions
Select an answer, then check it to see why each option is right or wrong.
T188 · Provider Network
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T189 · Group Insurance
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T190 · Certificate of Coverage
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T191 · Major Medical Insurance
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Sources & further reading
Original explanations and practice scenarios informed by the following regulatory, legal, and product resources. State examples are not presented as nationwide deadlines or requirements.