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

Maximum amount on which payment is based for covered health care services. This may be called "eligible expense," "payment allowance," or "negotiated rate." If your provider changes more than the allowed amount, you may have to pay the difference. (See Balanced Billing.) 

Ambulatory Care

Outpatient services, like a lab test or physical therapy.

Ancillary Services

These fall into three broad categories—diagnostic, therapeutic and custodial. A lab test is an example of a diagnostic ancillary service. Therapeutic ancillary services include speech therapy, physical therapy and psychotherapy. Custodial services involve patient care—like home health visits and nursing homes.

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

This is a type of complaint you can file if you disagree with the plan's decision to not cover healthcare services you're trying to get or have already gotten. You must file an appeal in writing within 60 days of the decision or as soon as you can. 

B

Behavioral Health Care

Also known as mental health care—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

In the Catastrophic Coverage Phase, you pay $0 for your drugs for the rest of the plan year, as long as those drugs are on your plan's formulary and you get them at an in-network pharmacy. You enter this phase once your total out-of-pocket drug costs for the year reach $2,000. This phase is now the third phase of your prescription drug plan.

Catastrophic Plans

Plans available on the Marketplace, 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 federally run entity that oversees the plans, rules and coverage of Medicare Advantage, PDP and Medicaid. It does not oversee Medicare Supplement, but it does oversee Original Medicare (Parts A & B). 

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)

Federal legislation that lets people buy health insurance for up to 18 months after they lose their job. This is valid if the company employed 20 or more people. 

Coinsurance

The percentage you pay for services at a doctor's office, pharmacy or hospital. 

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

If you have coverage from more than one insurance company, these rules help decide which plan pays first. This helps avoid overpayment. 

Copayment

The fixed dollar amount you pay for services at a doctor's office, pharmacy or hospital.

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

Children or a spouse covered on your plan. 

Description of Coverage (DOC)

A list of benefits and coverage, one per plan package. 

Direct Individual & Family Plans 

Individual & Family plans offered directly through Health Alliance, which offer more plan, doctor, and drug choices.

Disease Management

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

Dual Eligibility

This is for people who qualify for both Medicare and Medicaid at the same time. They're usually over the age of 65 with a low income.

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

This is the care you receive at an emergency room (ER) or emergency department. When you believe your health is at serious risk, seek emergency department care immediately. Don't hesitate to call 911 for assistance. 

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

The EOC is the primary document (like a policy) for how your plan covers your healthcare.

Exclusions

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

Explanation of Benefits (EOB)

A description of the healthcare service(s) you have received, listing what we paid and what you are responsible for paying. 

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 the health plan provider to manage the benefits they've chosen for its employees. Commercial group plans are either fully insured or self-funded.

G

Generic Drug

A drug that has the same active ingredients as a brand-name drug but costs less.

Grievance

This is a type of complaint you can make about your plan. Some examples are poor quality of care, bad customer service or feeling like an employee is encouraging you to leave the plan. You can file a grievance by calling our Member Services department within 60 days of the event or as soon as you can.

Group Health Insurance

Coverage through an employer or an organization.

H

Healthcare Effectiveness Data and Information Set (HEDIS)

A set of surveys that determines the level of care members are receiving and is used, in part, to determine CMS Star Ratings of Medicare plans.

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 give you care at discounted rates and have been vetted by your health plan as providing a high level of care. 

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

Medical Aid - State-administered health insurance program 

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

Medicare is the government-run insurance program for those 65 and older, or people with certain disabilities or end-stage renal disease (permanent kidney failure). 

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 Prescription Payment Plan (M3P)

If you experience hardship from high cost-sharing for prescription drugs as part of your Medicare Part D plan, the Medicare Prescription Payment Plan (M3P) allows you to spread out your out-of-pocket Part D drug costs through monthly payments over the course of the plan year (January-December) – instead of paying upfront at the pharmacy.

Medicare Supplement Plan

A type of Medicare plan that helps pay for medical costs Original Medicare doesn't pay for, but it generally only covers services Original Medicare already covers. It works in addition to Original Medicare. 

Member

A person covered under a health plan, either the enrollee or eligible dependent

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

Although your plan covers certain benefits, you still have to pay some or all of the costs for many of them. Out-of-pocket costs are teh costs you (rather than your health plan) pay. These can include: deductible, copay and coinsurance.

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)

With a POS plan, you choose an in-network primary care provider (PCP) to oversee your care and refer you to specialists. You have the flexibility to see out-of-network providers, but you may save money staying in network.

PPO (Preferred Provider Organization)

A plan that contracts with medical providers, such doctors, clinics and hospitals, to create a network or participating providers. You pay less if you use providers that belong to the plan's network. 

Prior Authorization

A review process your doctor must request for a specific drug or service to make sure you meet certain requirements before the health plan agrees to cover it.

Prior Authorization Penalty 

A charge you get if your doctor doesn't get prior authorization 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.

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 prior authorization 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.

Step-Therapy

A process requiring you to first try one drug before we agree to cover another drug. If Drug A and Drug B treat the same medical condition, Health Alliance may require you to try Drug A first. If Drug A doesn’t work for you, we will then cover Drug B. This requirement encourages you to try safer or more effective drugs before we will cover another drug. 

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