Answers from A to Z

Behavioral care services:

Assessment and therapeutic services used in the treatment of mental health and substance abuse problems.

Beneficiary:

A person who is eligible to receive benefits under a health benefits plan. Sometimes "beneficiary" is used for eligible dependents enrolled under a benefits plan; "beneficiary" can also be used to mean any person eligible for benefits, including both employees and eligible dependents.

Benefit year:

The coverage period, usually 12 months long, which is used for administration of a health benefits plan.

Benefits:

The portion of the costs of covered services paid by a health plan.

For example, if a plan pays the remainder of a doctor's bill after an office visit copayment has been made, the amount the plan pays is the "benefit." Or, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the "benefit".

Benefits package:

A term informally used to refer to the employer's benefits plan or to the benefits plan options from which the employee can choose. "Benefits package" highlights the fact a health benefits plan is a compilation of specific benefits.

Board-certified:

Any physician who has completed medical school, internship, and residency in his or her chosen specialty, and has successfully completed an examination conducted by a group (or board) of peers.

Brand-name drug:

A drug manufactured by a pharmaceutical company that has chosen to patent the drug's formula and register its brand name.

Care management:

Also called health management. Health care services and programs designed to help individuals with certain long-term conditions better manage their overall care and treatment.

Carrier:

A term historically used for licensed insurance companies, although now it is sometimes used to include both licensed insurers and HMOs.

Case management:

Coordination of services to help meet a patient's health care needs, usually when the patient has a condition requiring multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.

Centers for Medicare & Medicaid Services:

The federal agency responsible for administering the Medicare and Medicaid programs.

Centers of Excellence:

Centers of Excellence are hospitals or clinics that receive high scores for cost efficiency and effectiveness in treating selected procedures/conditions, based on publicly available patient data.

Charge Amount:

The amount billed by a provider for services rendered to a participant.

Claim:

A claim is a request for payment under the terms of a health benefits plan. A claim can be submitted by a member or by a provider.

Claim Status:

The state in which a claim exists, for example: paid, pending, etc.

Clinical Practice Guidelines:

Also called Medical Policy Guidelines. General procedures and suggestions about what constitutes an acceptable range of practices for particular diseases or conditions. These guidelines are usually developed by a consensus of doctors in a given field, such as radiology or cardiology.

Co-insurance:

The portion of eligible expenses that plan members are responsible for paying, most often after the deductible is met. Co-insurance is usually determined as a percentage of the total provider's actual charge, or the allowed amount.

Consolidated Omnibus Budget Reconciliation Act (COBRA):

A federal statute that requires most employers to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time (usually 18 months for employees and dependents who would otherwise lose coverage due to loss of employment or work hour reduction, or 36 months for dependents who would lose coverage for certain reasons other than employment loss by the employee).

Consultation:

A discussion with another health care professional when additional feedback is needed during diagnosis or treatment. Usually, a consultation is by referral from a primary care physician.

Consumer-Directed Health Care (CDHC):

A term that refers to health plans in which employees have a personal health account, such as a health savings account (HSA) and/or a health reimbursement arrangement (HRA), from which they pay medical expenses directly.

Consumer-Directed Health Plans (CDHP):

Consumer-directed health plans typically offer reduced premium costs, in exchange for a higher deductible. In addition, many provide incentives and tools to manage both health care decisions and the costs associated with them.

A typical consumer-directed plan also may include:

● Web-based tools that help you make decisions about your health plan choices, how much to contribute to your health savings account giving you  control over you health care decisions.

● Web-based educational information you need to make informed decisions about your healthcare, Preventive coverage at little or no cost  (deductibles do not apply), and/or

● Other support features, such as nurse telephone lines, care coaches and disease management programs.

Contract:

A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.

Contract holder:

The individual who holds the contract for covered health plan services (also called a subscriber).

Coordination of benefits:

A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate overinsurance or duplication of benefits.

Copayment:

The amount that a plan member must pay the provider at the time of service. Also called a copay, this amount varies depending on the specifics of a given health plan contract.

Coverage:

The benefits that are provided according to the terms of a participant's specific health benefits plan.

Covered Services:

Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health

benefits contract. The term defines the type and amount of expense that will be considered in the calculation of benefits.

Credentialing:

The process through which a health insurer reviews a health care provider's credentials against the criteria required to participate in a managed care network.

Custodial care:

Care that is provided primarily to meet the personal needs of a patient. The care is not meant to be curative or providing medical treatment.

Effective Date:

The date on which coverage under a health benefits plan begins.

Eligible:

The guidelines used to determine who qualifies for coverage under a health insurance plan.

Emergency:

An accident or sudden illness that an ordinary layperson believes needs to be treated right away or it could result in loss of life, serious medical complications, or permanent disability.

Important: If you believe that you are having a life-threatening medical emergency, call 911 or your local emergency number and seek medical help immediately.

Employee Assistance Program (EAP):

An EAP is an assessment and referral program or a short-term counseling program that some employers purchase from a health care insurer, and make available to their employees as part of health plan benefits.

Employee Retirement Income Security Act (ERISA):

A federal law that protects the retirement income of US workers, setting reporting and fiduciary requirements rules for participation, vesting, funding; and plan termination guarantees for certain plans to be insured and administered by the Pension and Benefits Guaranty Corporation (PBGC). PBCG is an insurance company that guarantees payment of pension benefits up to a specified maximum, in the event of plan termination.

Enrollee:

An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member or subscriber.

Exclusions:

Specific conditions or services that are not covered under the benefit agreement.

Experimental Procedures:

Experimental, investigational, or unproven procedures and treatments.

Explanation of benefits (EOB):

A statement provided by your health plan that explains the benefits provided, the allowable reimbursement amounts, any deductibles, co-insurance or other adjustments taken, and the net amount paid.

Extended care facility (ECF):

A medical care institution for patients who require long-term custodial or medical care, especially for chronic disease or a condition requiring prolonged rehabilitation therapy. Also called a long-term care facility.

Federal Mental Health Parity Act:

A federal act that prohibits group health plans from placing dollar limits on mental health benefits that would result in more restrictive coverage than that for medical health benefits.

Flexible Spending Account (FSA):

An account that reimburses the participant for qualified health costs or dependent care expenses through a pre-tax savings account. Employees fund the account, and at the end of each year, unused dollars are forfeited by the account holder.

Formulary:

A pre-approved list of commonly prescribed prescription drugs. Most health insurance companies maintain some kind of formulary. Formularies are usually developed by a committee of physicians and pharmacists, and include both brand-name and generic medications. Medications included in a formulary are usually covered by a health insurance plan's benefits.

Formulary management:

Clinical programs developed and maintained by plan doctors and pharmacists that help manage the utilization of covered medications by balancing clinical effectiveness with cost.

Generic drug:

A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand- name drugs and are typically less costly.

Generic substitution:

The use of a generic medication, instead of a brand name, when filling a prescription. Massachusetts (and several other states) have laws requiring generic substitution unless otherwise indicated by the prescribing physician.

Grievance:

A complaint about the quality of care or service you received from Blue Cross or a health care provider. A grievance should not dispute a coverage or payment decision.

Group health coverage:

A health benefits plan that covers a group of people, such as employees of a company, as permitted by state and federal law.

HIPAA:

Health Insurance Portability and Accountability Act of 1996. The law has several parts:

• The first part addresses health insurance portability and is designed to protect health insurance coverage for workers and their families when they change or lose their jobs. 
• Another part of the law is designed to reduce the administrative costs of providing and paying for health care through standardization.
• The law also includes requirements to protect the privacy of individuals protected health information. Health plans, providers, and other organizations with access to protected health information are covered by the requirements of HIPAA.

Health Care Financing Administration (HCFA):

The former name of the federal agency responsible for administering Medicare and federal participation in Medicaid. See Centers for Medicare & Medicaid Services.

Health Maintenance Organization (HMO):

An organization that arranges a wide spectrum of health care services which commonly include hospital care, physicians' services and many other kinds of health care services with an emphasis on preventive care.

Health Savings Account (HSA):

A financial vehicle in which members can pay for health costs through a fully insured, tax-exempt savings account. Employees or employers or both fund the account. An HSA is subject to regulations mandated by the federal government that limit coverage to IRS section 213(d) medical coverage. All unused amounts contributed by the employee carry over indefinitely during a participant's lifetime.

Health plan:

A term that has different meanings depending upon the context. "Health plan" can be used to mean an HMO, a health benefits plan provided by an employer to its employees, or a health benefits plan offered to employers by an insurer or third party administrator.

Health reimbursement arrangement (HRA):

A financial vehicle in which a member may be reimbursed for covered health expenses by his or her employer, up to a certain annual amount. Some employers allow employees to carry HRA balances over from one year to the next, however, most HRA balances are not portable, they revert to the company if the employee terminates his or her health coverage or employment.

Home Health Care:

Health services rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies, and special outpatient services.

Hospice:

A health care facility that provides supportive care for the terminally ill.

Hospital:

An institution whose primary function is to provide diagnostic and therapeutic inpatient services, for a variety of surgical and non- surgical medical conditions. In addition, most hospitals provide outpatient services, including emergency care.

The Health Plan Employer Data and Information Set (HEDIS):

A core set of performance measures developed through the collaborative effort of the National Committee for Quality Assurance (NCQA), employer groups, and health care purchasers. (HEDIS is a registered trademark of the National Committee for Quality Assurance.)

Joint Commission on Accreditation of Healthcare Organizations (JCAHO):

The JCAHO is an independent, not-for-profit organization whose mission is to improve the quality of care provided to the public through the provision of health care accreditation and related services that support performance improvements in health care organizations. The Joint Commission evaluates and accredits hospitals and health care organizations that provide managed care (including health plans, preferred provider organizations, and integrated delivery systems), home care, long-term care, behavioral health care, laboratory, and ambulatory care services.

Limitations:

There may be specific provisions in a group's health plan coverage that limit coverage of certain benefits to specific conditions or specific circumstances.

Long-term care:

The range of services typically provided at skilled nursing, intermediate-care, personal care, or elder-care facilities.

National Committee on Quality Assurance (NCQA):

An independent, nonprofit organization that assesses the quality of health care plans and verifies the credentials of those organizations.

Network:

A group of health care providers under contract with a managed care company within a specific geographic area.

Non-Participating Provider:

A medical provider who has not contracted with a health plan. 

Non-group health coverage:

Health care coverage purchased directly from a health insurance company, not through a group such as an employer. Sometimes called a direct-pay plan.

Qualified Medical Expense (QME):

Internal Revenue Code Section 213(d) defines qualified expenses, in part, as "medical care" amounts paid for insurance or "for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body..." To be eligible, these expenses must be to alleviate or prevent a physical defect or illness. Expenses solely for cosmetic reasons generally are not considered expenses for medical care.

Examples include facelifts, hair transplants and hair removal (electrolysis). Expenses that are merely beneficial to your general health (e.g., vacations) are not expenses for medical care. One fact or circumstance that often, but not always, indicates that medical care involves the treatment or prevention of disease is whether the care is prescribed by a physician. A mere suggestion by a physician probably is not enough. In addition, there should be a doctor-patient relationship between you and the physician prescribing the care.

Qualifying event:

An event that permits a member to modify his or her health benefits coverage. Examples of qualifying events include: marriage, birth or adoption of a child, or divorce.

Quality-care dosing:

A review of a medication that ensures both quantity and dosage are consistent with the recommendations of the Food and Drug Administration (FDA), manufacturer, and clinical recommendations.

Referral:

If a PCP determines that an individual requires specialized care, the PCP may "refer" that person to an appropriate specialist. A referral is often required by a managed care plan before the plan will cover certain services.

Rehabilitation:

Rehabilitation means the restoration of or improvement in an employee's health and ability to perform the functions of his or her job. It usually involves a program of clinical and vocational services with the goal of returning employees to a satisfying occupation if possible.

Service area:

The geographical area covered by a network of health care providers.

Skilled Nursing Facility (SNF):

A licensed facility that provides nursing care and related services for patients who do not require hospitalization in an acute care setting.

Specialists:

Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose, and throat), or specific procedures (e.g., oral surgery).

Speech Therapy:

Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior medical treatment.

Step therapy:

The process by which a physician is required to prescribe a first-line medication (often a more affordable generic medication) prior to prescribing a second-line, or brand-name medication.

Subscriber:

The primary, or "subscribing" member of a health plan. Some health plans use "subscriber" interchangeably with "enrollee".

Three-Tier Copayment:

A three-tier pharmacy program means that you'll pay one of three copayment levels for each prescription:

• Most generic drugs have the lowest copayment.
• Preferred brand-name drugs have a slightly higher copayment.
• Non-preferred drugs (the vast majority of which have a generic or preferred brand-name alternatives) require the highest copayment.

Tiers:

The level at which pharmacies or providers are categorized. Pharmacy tiers are related to copayments. Provider tiers are usually related to quality measures but can also be linked to cost measures.

Urgent Care:

The need to treat a medical condition that, while not an emergency, requires attention. Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections. Urgent situations are not considered to be emergencies.

Usual, customary, or reasonable (UCR):

The amount reimbursed to providers based on the prevailing fees in a specific area.

Utilization review:

The process of assessing the delivery of medical services to determine if the care provided is appropriate, medically necessary, and of high quality. UR may include review of appropriateness of admissions, services ordered and provided, length of stay, and discharge practices on a concurrent and retrospective basis.

Waiting Period:

In order to become eligible for coverage under certain group health plans, many companies require that an employee satisfy a certain number of continuous days of service as an active, full-time employee.