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GLOSSARY of HELPFUL DEFINITIONS

Health insurance, like any complicated subject, has its share of technical terms and abbreviations. To help, we've provided you with easy to understand definitions of some of the more common words and phrases used in talking about the subject. (Provided by Anthem Blue Cross.)

A

Adjudication: Determination of the amount of payment for a claim.  

Administrative Services Only (ASO): An arrangement under which an insurance carrier or an independent organization will, for a fee, handle the administration of claims, benefits and other administrative functions for a self-insured group but does not assume any financial risk for the payment of benefits. 

Ambulatory Surgery: Surgical procedures performed that do not require an overnight hospital stay. 

Ancillary Services: Hospital services other than room and board, and professional services. They may include X-ray, drug, laboratory or other services. 

Annual deductible: The amount you pay for covered expenses first, before an insurance plan begins to pay benefits. Some plans require deductibles for all services, some for just certain types of services; others require no deductible at all.

B

Behavioral Health: An Anthem Blue Cross mental/nervous and drug/chemical dependency program established in 1990. It combines a network of contracted providers and utilization management functions to deliver managed mental health care. 

Beneficiary: A person who is eligible to receive insurance benefits. 

Benefit: Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to others. 

Benefit Agreement: The written agreement between Anthem Blue Cross and a group or individual under which Anthem Blue Cross covers health care expenses, provides or administers health care benefits, or otherwise pays or arranges for the payment of benefits for health care services. 

Benefit Consultant: An individual or organization hired by a group planholder to review, analyze, and make recommendations on benefit strategies, including benefit plan design, carrier selection, pricing, etc. An insurance professional who provides information, advice and counseling for their clients.  

Benefit Period: The maximum length of time for which benefits will be paid.  

Board Certified*: This designates that the provider is Board Certified by the American Board of Medical Specialties (ABMS) in that particular specialty. The intent of the certification of physicians is to provide assurance to the public that a physician specialist certified by a Member Board of the ABMS has successfully completed an approved educational program and evaluation process which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty.

C

CaliforniaCare (HMO) Ready Access Program: Some CaliforniaCare (HMO) Medical Groups (PMG's and IPA's) participate in the Ready Access program. The Ready Access program consists of 2 parts, Direct Access and Speedy Referral. A PMG or IPA may participate in one or both parts of the Ready Access program.

Speedy Referral: allows your PCP to make expedited referrals to any one of the following 15 areas of specialty: Cardiology, Dermatology, Endocrinology, ENT (Otolaryngology), Gastroenterology, General Surgery, Hematology, Neurology, Oncology, Ophthalmology, Orthopedic Surgery, Podiatry, Routine Laboratory, Routine X-Ray and Urology.

Direct Access:  allows you, the member, to self-refer to one of the following 3 areas of specialty: Allergy/Immunology, ENT (Otolaryngology) and Dermatology.  Please verify each specialist's status with your Medical Group prior to making an appointment, as the physician's status is subject to change.

Co-pay/co-insurance: The flat amount or percentage you pay for a covered service after you satisfy the annual deductible, if any.

Covered expenses: Charges for services which are medically necessary and eligible for payment under the plan. A covered expense can be no more than the maximum amount stated in the plan.

D

Dependent: Person, (spouse or child), other than the subscriber who is covered under the subscriber's benefit certificate. 

Diagnostic Tests: Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Disease Management Programs (Health Management Programs): Educational programs designed for individuals with chronic diseases designed to help maintain high quality of life and prevent future need for medical resources by using an integrated, comprehensive approach to health care coordinate with the individual's physician. Pharmaceutical care, continuous quality improvement, practice guidelines, and case management all play key roles in this effort.  

Drugs, formulary: Drugs which the medical literature indicates are clinically effective, safe and of reasonable cost. The goal of our formulary list of prescription drugs, as established for the WellPoint Pharmacy Plan, is to identify and promote prescription drugs which are therapeutically appropriate and cost-effective.

Drugs, non-formulary: Prescription drugs not on our formulary list.

E

Emergency: A sudden, serious or unexpected acute illness, injury or condition which could permanently endanger your health if medical treatment is not received immediately.

Exclusions: Specific conditions or circumstances that are not covered under the contract. 

Experimental: Procedures that are not recognized under generally accepted medical standards as safe and effective for treating a particular condition. 

Expiration Date: The date coverage expires. 

Explanation of Benefits (EOB): A form sent to the covered person after a claim for payment has been processed by the carrier that explains the action taken on that claim. This explanation might include the amount that will be paid, the benefits available, reasons for denying payment, or the claims appeal process.  

Employee Retirement Income Security Act (ERISA): A federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs.  

G

Group insurance: A single policy issued to an employer under which employees and their eligible family members may be covered. Each employee receives a certificate of coverage outlining his/her health plan benefits.

H

Health Care Financing Administration (HCFA): Federal government agency that administers Medicare and Medicaid.  

Health Insurance Portability and Accountability Act (HIPAA): A federal health benefits law passed in 1996, effective July 1, 1997, which among other things, restricts pre-existing condition exclusion periods to ensure portability of health-care coverage between plans, group and individual; requires guaranteed issue and renewal of insurance coverage; prohibits plans from charging individuals higher premiums, co-payments, and/or deductibles based on health status.  

HMO (Health Maintenance Organization): An organization that provides a wide range of comprehensive health care services through a designated group, or network of doctors, hospitals, labs and other providers. To receive benefits, you must see the doctor you select as your primary care physician first for care or a referral, except in the case of an emergency. Your choice of doctors is restricted to those in the network.

Hospitals, non-contracting: Hospitals that are not part of the Prudent Buyer network and that have not signed a standard contract with us are considered non-contracting hospitals. We do not pay benefits for services provided by non-contracting hospitals except in the case of a medical emergency.

Hospitals, participating: Prudent Buyer (PPO) members admitted to Hospitals that have a PARTICIPATING Hospital status may require an additional co-payment as determined by your contract

Hospitals, preferred-participating: Prudent Buyer (PPO) members admitted into Hospitals with a PREFERRED Participating status will not have any additional co-payment amounts for services rendered.

I

Immunizations: Specific types of injections to prevent infectious diseases and viral infections. 

Inpatient: Service provided while the patient is admitted to the hospital for at least a 24-hour period.  

 (IPA) Independent Physicians Association: Primary Care Physicians (PCP) who practices in his/her own office, but is part of a larger network of many physicians. They will refer you to a specialist, usually close by, or to a medical lab for special work.

L

Lifetime Maximum: Maximum amount the plan will pay toward a member's coverage in a lifetime. The amount varies depending on the type of coverage the member carries.  

Limited fee schedule: A list of maximum amounts we will pay for certain services provided by non-network providers. You are responsible for paying your co-insurance and any amount over the limited fee schedule.

N

Negotiated fee:  The discounted rates that Prudent Buyer network doctors and hospitals agree to charge for covered expenses.

Network/ in-network: The term used for services received from doctors, hospitals and other providers contracting with us to provide care at the negotiated fee and to handle the paperwork.

O

Out-of-network/non-network: The term used for services received from doctors, hospitals or to the providers that are not part of the network. You pay substantially more for out-of-network services.

Out-of-pocket maximum: The most you pay for covered expenses during the year before the plan begins paying 100% of covered expenses for the rest of the year. Only covered expenses count toward the maximum. For example, any charges above the limited fee schedule for out-of-network doctor's services do not count.

Outpatient: A patient who is receiving ambulatory care at a hospital or other health facility without being admitted to the facility.  

Outpatient Surgery: Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center or physician office.  

P

PCP (Primary Care Physician):The doctor who serves as your CaliforniaCare (HMO) health care manager and coordinates virtually all of the health care services you receive. Your PCP provides you with routine medical care and refers you to a specialist if necessary.

PMG (Participating Medical Group): A group of doctors, both primary care physicians and specialists, who are practicing in one location to provide health care services. Most medical services, including special exams, X-Ray and laboratory tests are available in one convenient location.

PPO (Preferred Provider Organization): Health care providers who are under contract to provide care at discounted or fixed fees. Unlike HMOs, health plans with a PPO allow you to choose any doctor at any time. However, if you select a non-PPO provider you will pay more out of pocket for services than you would if you selected a PPO "network" provider.

Pre-existing condition or pre-existing waiting period: If you receive medical advice, or treatment was recommended or received for any accident, illness, or other medical condition during six months before you enroll in a plan, you won't be covered for the care you receive as a result of that condition until you've been enrolled in the plan for six months. If you satisfied the six-month waiting period while enrolled in another medical plan, and enrolled within 30 days of completing that waiting period, you won't need to complete another pre-existing waiting period. You will receive partial credit if you were insured under another plan for less than six months.

Prudent Buyer PPO: The Preferred Provider Organization.

Q

Qualifying prior coverage: Any individual or group plan that provides medical, hospital, and surgical coverage, including continuation or conversion coverage or coverage under a publicly sponsored program such as Medicare or Medicaid. It does not include accident only, credit, disability income, Medicare supplement, long term care insurance, dental, vision, workers' compensation insurance, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans.

R

Referral: A recommendation by a physician or insurer that an individual receive care from a different doctor or facility. 

S

Second Opinion: The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.  

Service Area: The geographic area that an insurer, health plan or health care provider services.  

Senior Secure: An Anthem Blue Cross HMO plan operating in a defined geographic area under a Medicare risk contract with the federal Health Care Financing Administration (HCFA). In addition to physician care, hospitalization and other benefits covered by Medicare, the benefits under this plan include prescriptions drugs, routine physical exams, hearing tests, immunizations, eye examinations, counseling and health education services.  

Skilled Nursing Facility: An institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. 

Specialist: a physician whose practice is limited to a particular branch of medicine or surgery.

Speech Therapy: Treatment or the correction of a speech impairment that resulted from birth, or from disease, injury or prior medical treatment. 

Subscriber: The individual in whose name a contract is issued or the employee covered under an employer's group health contract.  

Substance Abuse/Chemical Dependency: Conditions that include, but are not limited to (1) psychoactive substance induced mental disorders; (2) psychoactive substance use dependence; and (3) psychoactive substance use abuse. Chemical dependency does not include addition to or dependency on, tobacco or food substances (or dependency on items not ingested).  

U

Urgent Care: The services received for a sudden, serious, or unexpected illness, injury or condition, other than one which is life threatening, that requires immediate care for the relief of severe pain or diagnosis and treatment of such condition.  

W

Well Baby/Well Child Care: Routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six. 

Wellness Program: A health management program that incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability, which respond positively to lifestyle related interventions. Programs are designed to integrate with existing health care benefits; e.g., flex benefits, HMO, PPO; support the reduction in the demand for health care resources; and address the issues of dependent coverage and services for high-risk employees.  

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