Enrollee

An enrollee is a person who is eligible to receive or is receiving benefits from a health maintenance organization (HMO) or other insurance plan. This includes not only those who have subscribed to the plan but also the subscriber's eligible dependents. Eligible dependents may be a spouse, a child, an adult child who is disabled, or an elderly parent.

All enrollees must meet the health plan's eligibility requirements, be currently enrolled in the plan, and accept financial responsibility for premiums, copayments, and deductibles. Premiums are the annual or monthly payments made to the plan to have the health benefit. Copayments are the per-visit outlay for a service covered by the plan. Deductibles are the annual amount paid out of pocket before the plan starts coverage.

The benefit package is the list of covered services that an insurance company, HMO, or preferred provider organization (PPO) offers a group or individual in its health plan. Basic benefits are a set of basic health services specified in the member's certificate. Basic benefits are services that are required under applicable federal and state laws and regulations.

An enrolled group consists of individuals with the same employer or membership in an organization in common, who are enrolled collectively in a health plan. The health plan may stipulate that the group be of a certain size and [Page 182]that a certain percentage of that group must enroll before the coverage is made available to them.