Additional Terms and Definitions

A

Accreditation

Shows that a health plan meets standards set by an official review committee or organization.

Acute Care

Short-term care for an illness or health problem.

Adjudication

The process of paying or denying claims after comparing them to a member’s benefits.

Affordable Care Act (ACA)

A law, as of March 2010, that works to improve the quality of American health care. As of 2014, the ACA requires most people to have health insurance.

Agency for Healthcare Research and Quality (AHRQ)

Agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

Allowed Charge

The most a health plan will pay for a service or procedure.

Ambulatory Care

Outpatient services, like a lab test or physical therapy.

Ancillary Services

Services that fall into diagnostic, therapeutic, or custodial categories. A lab test is an example of a diagnostic service. Speech therapy, physical therapy, and psychotherapy are therapeutic services. Patient care, like home health visits and nursing homes, are custodial services.

Annual Enrollment Period (AEP) or Annual Election Period

From October 15 to December 7, when you can enroll in Original Medicare, a Medicare Advantage plan, a stand-alone Part D plan, or switch plans.

Annual Out-of-Pocket Maximum

Once members have paid this amount, we pay 100% of covered expenses for the rest of the benefit period. You will no longer pay copayments or coinsurance, just your monthly premium.

Appeal

A kind of complaint you make to your health plan about your plan’s benefits, coverage, or payments, like a certain medical service or prescription drug not being covered.

B

Behavioral Health Care

Treatment for conditions like depression, eating disorders, and substance abuse.

Benefit Period

The time period your plan is active for, normally January 1 to December 31.

Brand-Name Drug

A prescription drug that’s produced and sold by the same pharmaceutical company that researched and developed it. Brand-name drugs usually cost more, even though they have the same active ingredients as their generic versions.

Broker

A licensed independent salesperson for health insurance companies.

C

Cafeteria Plan

Plans that include the option for Flexible Spending Accounts (FSAs).

Care Coordination

Programs designed to provide support and resources to help members understand and better manage illness and recovery including how to prevent illness and hospital stays.

Catastrophic Coverage

When a Medicare member with prescription drug coverage reaches their pharmacy spending maximum and leaves the Coverage Gap, they enter the Catastrophic Coverage Period. During this period, we pay for most of your drug costs.

Catastrophic Plans

Plans, for people under 30 years old who don’t have access to affordable coverage, with low-cost protection and high out-of-pocket costs.

Centers for Medicare & Medicaid Services (CMS)

The federal agency that runs the Medicare program and works with states to run Medicaid.

Children’s Health Insurance Program (CHIP)

Health services for low-income families with children who don't qualify for Medicaid.

Claim

What your provider or pharmacy sends us for payment of a service, above any copayment or coinsurance you pay.

Claim Provisions

Rules for filing claims and for the claims appeals process.

Clinical Practice Guidelines

The set of standards designed to help doctors make decisions about treating patients.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

The federal law that lets people buy health insurance for up to 18 months after they lose their job, if the company employed 20 or more people.

Coinsurance

The percentage of the cost you pay each time you use a medical service covered by your plan.

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

Survey that asks consumers and patients to report and evaluate their experiences with health care.

Continuation

When you lose your health care coverage due to a qualifying event, like a divorce, and are able to keep your coverage for a certain period.

Coordination of Benefits

Rules that help decide which plan pays first if you have coverage from more than one insurance company.

Copayment

The set fee you pay each time you use a medical service covered by your plan.

Coverage Gap

If you have Medicare prescription drug coverage, you enter the Coverage Gap when your total yearly drug costs, both what you and your plan paid, reach a certain amount. During this time, you pay most of your drug costs.

Credentialing

Approval process to make sure doctors and hospitals meet certain standards.

D

Deductible

A set amount you pay before your plan starts helping pay for your medical care or pharmacy benefits. Some plans have separate medical and pharmacy deductibles.

Dependents

A subscriber’s spouse or children covered on the plan.

Description of Coverage (DOC)

A chart listing a plan's most common benefits.

Direct Marketplace

Where you can shop for all of our individual private plans, which offer more plan, doctor, and drug choices.

Disease Management

Programs that help people with chronic illnesses better manage their health.

Dual Eligibility

People who qualify for both Medicare and Medicaid at the same time. To qualify, you must have Medicare Parts A and B, and you must get Medicaid benefits that pay for all or part of your Medicare copayments, coinsurance, and deductibles.

Durable Medical Equipment (DME)

Medical equipment that’s prescribed by your doctor for use in your home, like wheelchairs, crutches, hospital beds, oxygen equipment, and walkers.

E

Effective Date

A plan’s start date.

Emergency Care

Care provided in an emergency medical situation where you believe your health is in serious danger, like chest pain, a broken bone, poisoning, shortness of breath, fainting, seizures, and unconsciousness.

Employee Assistance Programs (EAP)

Programs to help employees balance work and life issues with support and counseling for stress, family, and financial issues.

ERISA (Employee Retirement Income Security Act)

The law controlling many employer-based health plans that sets rules for pensions and other benefits plans.

Evidence of Coverage

A document you get when you enroll in a Medicare plan, and each fall you remain on that plan, that explains its details, including a complete list of your benefits, the services we cover, and what you pay for each service.

Exclusions

Conditions or services we will not pay for that are listed in your policy.

Explanation of Benefits (EOB)

A description of services that lists what we paid.

F

Family Deductible

The combined dollar amount all family members' expenses must reach before benefits for any member on the plan start.

Flexible Spending Accounts (FSAs)

Account that lets employees set aside money tax-free from their paychecks for medical expenses. These funds are available for a set benefit period.

Formulary

A list of drugs covered by your plan that includes generic and brand-name drugs. Our Pharmacy Department and doctors decide what drugs to include based on quality, safety, and how well they work.

Fully Insured Plan

A health plan where an employer pays a health plan provider to manage the benefits they've chosen.

G

Generic Drug

Drugs with the same active ingredients as the brand-name versions that are reviewed and approved by the Food and Drug Administration (FDA). They cost less because their makers don’t have to spend money on research, development, and marketing.

Grievance

This is a complaint you make about the quality of care your health plan is giving, like the customer service you received, waiting times, or how an employee acted toward you.

Group Health Insurance

Coverage through an employer or an organization.

H

Healthcare Effectiveness Data and Information Set (HEDIS)

Tool used by more than 90% of America’s health plans to measure performance of care and service.

Health Coaching

A program to help you plan for better health, get the best care possible, and make the most of your coverage.

Health Savings Account (HSA)

Account that lets employees set aside money tax-free for medical expenses. Individuals, employers, and employees can add to these savings accounts. These funds are not on a time limit.

High Deductible Health Plan (HDHP)

A plan where you pay higher out-of-pocket costs in exchange for a lower monthly premium.

HIPAA (Health Insurance Portability and Accountability Act)

A federal law protecting private health information.

HMO (Health Maintenance Organization)

A plan with personal care from a set network. You’ll need to choose a personal doctor, called a Primary Care Physician (PCP), to manage your care and refer you to specialists. You must go to certain doctors and hospitals, unless it’s an emergency or for urgent care.

Home Health Care

Medical care, treatment, or skilled care you get in your home.

Hospice Care

Special care for people who are terminally ill, including medical and physical care and help with social, emotional, and spiritual needs. It also provides support for family and caregivers.

Hospitalist

A dedicated, in-patient doctor who works only in a hospital or network of hospitals.

I

Initial Enrollment Period (IEP)

A 7-month period, which includes the 3 months before your 65th birthday, the month of your birthday, and the 3 months after your birth month, when you can enroll in Original Medicare, a Medicare Advantage plan, a Stand-Alone Part D plan, or a Medicare Supplement plan for the first time.

In-Network

The group of doctors, hospitals, pharmacies, and other health care professionals who have agreed to provide services to our members.

In-Network Pharmacy

Pharmacies that have agreed to provide prescription drugs to our members.

In-Network Provider

Providers that have agreed to provide services to our members.

Inpatient Care

The health care services you get when you’re staying in the hospital.

Individual Coverage Health Reimbursement Arrangement (ICHRA)

An alternative to offering a traditional group health plan to your employees.

J

K

L

Long-Term Disability Insurance

Insurance that pays a percentage of your monthly earnings if you become disabled.

M

Managed Dose Limitation (MDL)

Policy that limits the amount of certain drugs you’re given based on the drug maker’s package size and what the Food and Drug Administration (FDA) recommends.

Medicaid

A shared federal and state program that helps people with low incomes pay for medical costs.

Medical Director

A leader who recruits and manages doctors, nurses, and other personnel, and examines and coordinates processes within their organizations to improve and guarantee the medical quality of the facility.

Medically Necessary

Drugs, medical services, or supplies needed for diagnosing or treating a certain illness or injury. You must use the drug, service, or item regularly, and it must be considered the most appropriate care that can be safely provided to you. The service can’t be used only for convenience.

Medicare

The health insurance program run by the Centers for Medicare & Medicaid Services (CMS) for people age 65 and older and some younger than 65 with disabilities.

Medicare Advantage Plans

Part C plans that are sold by private companies with a Medicare contract that include coverage for both Part A and Part B, and sometimes Part D.

Medicare Part A (Hospital Insurance)

Helps cover hospital costs like room and board, other inpatient care provided in a hospital or skilled nursing facility, hospice care, and some home health care. Most people don’t have to pay a premium for Part A because they already paid for it through taxes. Part A is included in Original Medicare.

Medicare Part B (Medical Insurance)

Helps cover medical costs like doctor visits, other outpatient care, and some other medical services Part A doesn’t cover, like physical therapy. With Original Medicare, you can buy Part B for a monthly premium.

Medicare Part C (Medicare Advantage)

Medicare Advantage plans that are sold by private companies with a Medicare contract that include coverage for both Part A and Part B, and sometimes Part D.

Medicare Part D (Prescription Drug Coverage)

An optional program sold by private companies with a Medicare contract to help cover your prescription drug costs. You can get Part D by buying stand-alone prescription drug plans or Medicare Advantage plans that include Rx coverage.

Medicare Part D Formulary

A list of drugs covered by your Medicare Part D plan that includes generic and brand-name drugs. Our Pharmacy Department and doctors decide what drugs to include based on quality, safety, and how well they work.

Medicare Supplement Plan

A type of Medicare plan that helps cover medical costs Original Medicare doesn’t cover.

Member

Customer, individual, or person who has insurance coverage with Health Alliance.

Mental Health Care

Treatment for conditions like depression, eating disorders, and substance abuse. Also called Behavioral Health Care.

N

National Committee for Quality Assurance (NCQA)

The NCQA is a non-profit organization dedicated to improving health care quality. They accredit and certify a wide range of health care organizations.

Network

The group of doctors, hospitals, pharmacies, and other health care professionals who have agreed to provide services to our members.

Non-Formulary

Medicine not listed on our formularies. Your doctor needs to request an exception if you need one of these drugs.

Notice of Privacy Practices

A document that describes how your health plan may use and disclose your health information and your rights regarding this information.

Nurse Navigator

A nurse who helps you handle your care when you’re discharged from the hospital if you get a serious diagnosis.

O

Open Enrollment Period (OEP)

The only time of year you can enroll in an individual insurance plan, (unless you have Medicare,) from November 1 to January 15.

Original Medicare

The health insurance program, made up of Medicare Part A and Part B, run by the Centers for Medicare & Medicaid Services (CMS) for people age 65 and older and some younger than 65 with disabilities.

Out-of-Network

Doctors, hospitals, pharmacies, and other health care professionals that are not a part of your health plan’s provider network or pharmacy network.

Out-of-Network Pharmacy

A pharmacy that is not a part of your health plan’s pharmacy network, so your drugs won't be covered if you get them there.

Out-of-Network Provider

A provider that is not a part of your health plan’s provider network.

Out-of-Pocket Costs

Costs you must cover, like deductibles, coinsurance, copayments, and any costs above the amount we allow.

Out-of-Pocket Drug Costs

What you pay for prescription drugs.

Out-of-Pocket Maximum

Once you have paid this amount, we pay 100% of covered expenses for the rest of the benefit period. You no longer pay copayments or coinsurance, just your monthly premium, as long as your copayment or coinsurance applies to the OOPM. In-network services (also referred to as Tier 1 and Tier 2) both apply to the in-network OOPM. Note that if you receive services that are non-covered or use out-of-network providers (referred to as Tier 3), you may be required to cover costs above the OOPM. There is no cap on the amount that you may have to pay for non-covered services or using out-of-network providers.

Outpatient Care

Medical care or treatment that doesn’t include staying overnight in a hospital.

P

Palliative Care

Care, also called comfort care, that's given to relieve pain, not cure, like hospice.

Part A

Helps cover hospital costs like room and board, other inpatient care provided in a hospital or skilled nursing facility, hospice care, and some home health care. Most people don’t have to pay a premium for Part A because they already paid for it through taxes. Part A is included in Original Medicare.

Part B

Helps cover medical costs like doctor visits, other outpatient care, and some other medical services Part A doesn’t cover, like physical therapy. With Original Medicare, you can buy Part B for a monthly premium.

Part C

Medicare Advantage plans that are sold by private companies with a Medicare contract that include coverage for both Part A and Part B, and sometimes Part D.

Part D

An optional program sold by private companies with a Medicare contract to help cover your prescription drug costs. You can get Part D by buying stand-alone prescription drug plans or Medicare Advantage plans that include Rx coverage.

Participating Provider

Providers that have agreed to provide services to our members.

Pharmacist

Healthcare professionals who practice pharmacy, which focuses on safe and effective medication use.

Pharmacy Directory

A list of the pharmacies you can use to fill your prescriptions.

Pharmacy Network

Pharmacies that have agreed to provide prescription drugs to our members.

POS (Point of Service)

A plan with personal care and the freedom to go out-of-network. You’ll need to choose a personal doctor, called a Primary Care Physician (PCP), to manage your care and refer you to specialists.

PPO (Preferred Provider Organization)

A plan with the freedom to go out-of-network, but you will pay less if you go to in-network doctors and hospitals.

Preauthorization

A review process your doctor must request for a drug or service before you get it to make sure you meet certain requirements before we agree to cover it.

Preauthorization Penalty

A charge you get if your doctor doesn’t get preauthorization for certain drugs or services before you get them.

Premium

The monthly amount a member or group pays for coverage.

Preventive Services

Services like tests, screenings, and vaccines that help keep you healthy or prevent getting sick, like flu shots, mammograms, and Pap tests.

Primary Care Provider (PCP)

A personal doctor you choose to manage your care and refer you to specialists.

Provider

Doctors, other health care professionals, hospitals, and other health care facilities.

Provider Directory

The list of all the in-network doctors and hospitals you can use.

Provider Network

Providers that have agreed to provide services to our members.

Public Exchange

The Affordable Care Act (ACA) says each state must have a Public Exchange, or a marketplace, to buy insurance.

Q

Qualifying Event

A life-changing event that lets you change your health plan, like moving, getting married, or having a baby.

Quality Improvement (QI) Program

A program that sets aside time and resources to improve care and services for our members.

Quantity Limits

Policy that limits the amount of certain drugs you’re given based on the drug maker’s package size and what the Food and Drug Administration (FDA) recommends.

R

Referral

A process that lets you get care from a specialist or hospital, usually through your primary care physician (PCP).

Renewal

When a member or group signs up to continue their insurance plan for another benefit period, sometimes with changed terms, like new rates.

Rider

A document that's separate from the main policy that changes a benefit or adds a new one.

S

Self-Funded Plan

A type of plan where the employer takes on the risk and the costs of their employees’ health care to save money.

Service Area

The location you must live in to enroll in certain plans.

Short-Term Disability Insurance

Insurance that pays part of your wages when you're out of work because of an illness or injury that's not related to work.

Short-Term Plans

Plans that help you with medical costs if you change jobs, missed enrollment, or are waiting until you can begin other coverage. They're not recognized by the government, so you'll still be charged a fee for not having insurance.

Skilled Care

Medical care ordered by a doctor and given or supervised by a licensed health care professional.

Skilled Nursing Care

Medical care ordered by a doctor that must be given or supervised by a licensed health care professional in a skilled nursing facility. Skilled nursing care includes:

• Doctor services and regular nursing services.
• X-rays and other radiology services.
• Lab tests.
• Physical, occupational, and speech therapy.
• Storage and administration of blood.
• Use of appliances, like wheelchairs.
• A semiprivate room or private room if medically necessary.
• Meals, including special diets.
• Meds prescribed to you as part of your treatment plan.

Skilled Nursing Facility

A nursing home, hospital, or part of a facility that provides residents with medical care ordered by a doctor, rehab services, or both.

Small Business Health Options Program (SHOP) Marketplace

Businesses with 50 or fewer full-time employees can use this marketplace to offer coverage to their employees.

Social Worker

Social workers are there to help you with social problems that can affect your quality of life and health care.

Special Enrollment Period (SEP)

Special cases when you can enroll or make changes in your plan outside of the Open Enrollment Period (OEP) or Annual Enrollment Period (AEP), like changing jobs, moving, getting married, or having a baby.

Specialist

A doctor who provides health care services for a specific disease or part of the body, like dermatologists, who focus on skin care.

Specialty Drug

Drugs that help members deal with complex diseases like cancer, rheumatoid arthritis, and multiple sclerosis. Doctors must request preauthorization for most of them and closely watch how they're used, stored, and given, (like orally, injected, or by IV,) either at a health care facility or at home.

Stand-Alone Prescription Drug Plan

An optional program sold by private companies with a Medicare contract to help cover your prescription drug costs.

Step-Therapy

A requirement which encourages you to try safer or typically more effective drugs before we will cover another drug.

If a doctor thinks it’s medically necessary to skip the prerequisite, they can request a preauthorization.

Stop-Loss

Coverage a self-funded group can buy to protect themselves from losses due to catastrophic claims. If health care costs go over the amount in the contract, we pay the rest.

Subscriber

The person whose name is on an individual policy, (the policy owner or holder,) or employees on group policies.

Summary of Benefits (SOB)

A summary of services a plan covers and what you pay for each service.

For Medicare plans, it also compares what you pay for services with Original Medicare to what you pay for services with a Medicare Advantage plan.

Summary of Benefits and Coverage (SBC)

A summary of what a plan covers and what it costs. This document answers common insurance cost questions and explains a plan's coverage for some common medical events.

Surgeon

A doctor who is qualified to perform surgery, usually within a specialty.

T

Termination Date

The date your plan ends.

Tier (Pharmacy Tier)

Every drug listed in our formularies is put into one of these cost groups. For the lowest tier, you pay the lowest copayment. As you take a step up to the next tier, what you pay increases.

Transitional Plans

Transitional plans are not fully compliant with the Affordable Care Act (ACA). These plans were purchased between March 23, 2010, when the ACA was signed into law, and December 31, 2013.

U

Urgent Care

A non-emergency situation where your health is not in serious danger, but because of an illness or injury you need medical care to keep it from getting worse, like constant fever, bronchitis, sprains, and unresponsive migraine headaches.

Utilization Management

Managing the use of medical services to make sure you get affordable, necessary, high-quality care through step-therapy, preauthorization, and managed dose limitations.

V

W

Waiting Period

The stretch of time, also known as a probationary period, an employer can make a new employee wait before getting coverage.

WHCRA (Women's Health and Cancer Rights Act)

A law requiring plans to cover reconstructive surgery following a mastectomy.

Worker's Compensation (Workmen’s Comp)

This law makes sure your medical costs are covered and that you get disability pay after you’ve been hurt at work.

X

Y

Z