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This chapter covers the health insurance products available to California seniors — the government-sponsored Medicare and Medi-Cal programs, and the privately sold Medicare Supplement (Medigap) policies that fill the gaps Medicare leaves behind. You will also learn how the Health Insurance Counseling and Advocacy Program (HICAP) assists Medicare beneficiaries at no cost, and the CMS marketing and compliance rules producers must follow when working with Medicare-eligible clients. This chapter is dense with eligibility rules, dollar figures, and enrollment periods — as you work through it, try applying each rule to a hypothetical client to help the details stick.
| Term | Definition |
|---|---|
| Benefit period | A period of time during which benefits are paid under the policy |
| Cost-sharing | Sharing of expenses between the insured and the insurance company through deductibles, copays, and coinsurance |
| Enrollee | A person enrolled in a health insurance plan, an insured (does not include dependents of the insured) |
| HMO | Health Maintenance Organization — a prepaid medical service plan in which specified medical service providers contract with the HMO and which focuses on preventive care |
| Network provider | A provider who enters into a contractual arrangement with other providers to provide medical services to network subscribers |
| Outline of coverage | A document required in all health insurance policies that provides a full coverage disclosure to the applicant |
Terms to Know