Glossary of Terms... 

These terms are defined for general information purposes only; certain terms may have varying definitions based on state law.
 

Allowable Expense

Any necessary and reasonable health expense, part or all of which is covered under any of the plans covering the Member for whom claim is made.

Capitation

The prepaid amount which the provider receives as compensation for Capitation Services.

Case Management

A process of identifying individuals at high risk for problems associated with complex health care needs, assessing opportunities to coordinate care, control costs and manage a member's full spectrum of care to optimize outcome.

Coinsurance

The portion of covered expenses which a member must pay for care, after first meeting a deductible amount, if any.

Coordination of Benefits (COB)

A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their claims and providing the authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision, it does not have to pay its benefits first. Refer to the Coordination of Benefits section of your applicable plan document.

Copayment

A charge required under a Plan that must be paid by a Member at the time of the provision of Covered Services.

Credentialing

A systematic approach to assessing the qualifications of potential and existing providers through a review of relevant training, experience, licensure, certification, and/or registration to practice in a health care field; includes review of historical records to ascertain that potential providers have the required academic background and an acceptable record on issues relating to professional competence and conduct.
 

Deductible

An amount that a Member must pay for Covered Services per specified period in accordance with the Member's Plan before benefits will be paid.

Dependent

A person other than the enrollee who is eligible to receive care under a plan's provisions. Examples would be a spouse or child.

Direct Access

Under certain lans, you (the member) may have “direct access” (sometimes referred to as “open access”) to any participating provider of a specified specialty without a referral.  

Drug Formulary

A listing of prescription drugs and insulin established by the health plan which includes both Brand Name Prescription Drugs, and Generic Prescription Drugs. This list is subject to periodic review and modification by the health plan. Drugs listed on the formulary are covered under our managed prescription drug plans, with copayments that may vary based on plan design. Certain non-formulary drugs are also covered under some plan designs.

Emergency

Emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (I) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.

Explanation of Benefits

Explanation of Benefits forms are provided to members to explain how the payment amount for a health benefit claim was calculated. Among other things, the Explanation of Benefits may explain the claims appeal process.

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is a federal law enacted in 1996. It was designated to improve availability and portability of health coverage by:

·          limiting exclusions for pre-existing conditions;

·          providing credit for prior health coverage;

·          allowing transmittal of the coverage information (i.e., covered family members and coverage period) to a new insurer;

·          providing new rights to allow individuals to enroll for health coverage when they lose their health coverage or have a new dependent;

·          prohibiting discrimination in enrollment/premiums

·          guaranteeing availability of health insurance coverage for small employers.

Health Maintenance Organization (HMO)

An HMO (Health Maintenance Organization) is a managed care program.  Most HMO's require each family member to select a Primary Care Physician from an approved list provided by the HMO.  This Primary Care Physician will then direct all of your medical treatment including referring you to a specialist.  This specialist is usually a member of the HMO you are insured with.  Failure to see your selected Primary Care Physician first (unless in an emergency situation) can result in sharply reduced benefits or no benefit at all.  As a general rule, HMO's provide the most comprehensive medical care; such as routine office visits, physical exams, well-baby care and immunizations.  HMO's also feature low office visit co-payments and usually do not require the filing of claim forms.

Indemnity Plan

A traditional indemnity plan allows members flexibility in their choice of recognized health care providers. Members are responsible for seeking care, initiating precertification, paying for services rendered, and submitting claims for reimbursement of covered services at a predetermined coinsurance rate.

Independent Practice Association (IPA)

A legal entity or other group of providers that contract with managed care plans while maintaining their separate practice. A member who selects an IPA-affiliated primary care office generally will be referred to specialists and hospitals affiliated with the IPA, unless the member's medical needs extend beyond the capability of these providers.

Network

Physicians, hospitals and other health care providers who contract with the companies to participate in health benefits plans. For certain HMO and PPO plans, a member must access care through the network to receive the maximum level of benefits.

Outpatient

Care provided in a clinic, emergency room, hospital or non-hospital surgical facility ("SurgiCenter") without admission to the hospital or facility.
 

Participating Provider

Any physician, hospital, skilled nursing facility, or other individual or entity involved in the delivery of health care or ancillary services which contracts to provide Covered Services to Members.

Plan Documents

Plan documents include the Group Agreement, Group Policy, and Certificate or Evidence of Coverage (or Certificate of Insurance).

Point-of-Service Plan

A point of service plan provides benefits for covered services received from both participating and non-participating providers. When you enroll in a point-of-service plan, you choose a primary care physician (PCP) for yourself and each covered dependent. In order to receive the higher level of benefits under the plan, you must access care through your PCP, except for emergency care or direct access benefits. Your are responsible for a copayment. Care received on a self-referral basis may be subject to a reduced level of benefits than care accessed through your PCP, except for direct access benefits. You are responsible for a deductible and coinsurance percentage for self-referred services.

Preauthorization / Precertification

For certain Aetna U.S. Healthcare plans, you must obtain authorization from Aetna U.S. Healthcare prior to receiving certain non-emergency medical services.

Preferred Provider Organization  

A PPO plan (Preferred Provider Organization) combines elements of a Major Medical plan with an HMO.  There is a list of Preferred Providers of doctors and hospitals you can choose from, but you are free to choose an out-of-network doctor or hospital.  However, if you choose an out-of-network provider, you will probably have to pay an increased percentage of the cost.  A typical plan may provide that in-network provider services are provided with an 80/20 co-insurance percentage, while out-of-network provider services would be provided with a 60/40 co-insurance percentage. You usually will have to pay a deductible and a co-insurance payment with a PPO plan

Primary Care Physician:

A Participating Physician whose area of practice and training is family practice, general medicine, internal medicine or pediatrics, or who is otherwise designated as a Primary Care Physician (“PCP”) by Company. A PCP has agreed to provide primary care services and to coordinate and manage all Covered Services for Members who have selected such Participating Physician, if the applicable Plan requires a Primary Care Physician for maximum reimbursement of covered benefits.
 

Referral

Specific directions or instructions from a Member's PCP, in conformance with HMO's policies and procedures, that direct a Member to a Participating Provider for Medically Necessary care.
 

Specialist

A Physician who provides medical care in any generally accepted medical or surgical specialty or subspecialty.
 

Traditional Major Medical

A Traditional Major Medical plan is one in which your insurance company will  reimburse you for covered medical expenses after certain conditions are met. One of these conditions is that you will have to pay a deductible.  Deductibles can range from $50 to $5,000.  As a general rule, the higher the deductible, the lower the premium cost.  A second conditon is a Traditional Major Medical plan typically requires you to pay a portion of the cost above the deductible, this is often referred to as co-insurance.  Typically, the co-insurance amount is expressed as a percentage of the claim amount above the deductible. A common  co-insurance percentage is 80/20, where the insurance company pays 80% and you pay 20%. At Quotesmith.com, you can find plans with deductibles from $50 to $5,000 and co-insurance percentages from 50/50 to 100/0. As a general rule, you will be able to choose your doctor without reference to an approved list provided by the insurance carrier.