Definition: In the context of health insurance, a ‘Member’ refers to an individual who has enrolled in a health insurance plan. This individual can be the subscriber who holds the insurance policy, or an eligible dependent for whom coverage is provided under the subscriber’s policy. The health organization, upon issuance of the policy, agrees to cover health services contracted for the Member under the terms stipulated in the plan.
Key Aspects:
Subscribers: These are primary holders of the health insurance policy. They register either individually or for their family, including spouses and children, for health care services provided under the plan.
Eligible Dependents: Eligible dependents can include the subscriber’s spouse, children, or other individuals defined as dependents by the insurance policy. Their healthcare services are covered under the same health insurance plan subscribed to by the primary policyholder.
Coverage Responsibility: The responsibility accepted by a health organization relative to a Member includes not just enrollment but also the ensuring of timely access to all health services outlined in the contract, as well as compliance with all applicable care guidelines and pricing.
Important Regulations:
Certain laws and regulations govern how entities handle the provision of health care to members. This includes various stipulations under the Affordable Care Act (ACA) and other related healthcare guidelines. Familiarizing oneself with these regulations can help members and subscribers understand their rights and obligations.
