A group of doctors, hospitals and other health care providers who come together to give coordinated high-quality care to their patients.
A review process that ensures that a health insurance issuer meets an acceptable level of standards. Accreditation indicates that the issuer has passed the review and is appropriately qualified.
A tax credit that can help you afford coverage on individual, qualified Marketplace plans. Sometimes known as “APTC”, advance payments of the premium tax credit, or “premium tax credit.” Unlike tax credits you claim when you file taxes, these tax credits can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of the advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.
A shortened term for the Patient Protection and Affordable Care Act (PPACA). “Obamacare” is another term people use when they talk about this law. The ACA includes changes that aimed to expand access to coverage, control health care costs and improve health care delivery for U.S. citizens and legal residents. Most U.S. citizens and legal residents are now required to have health insurance coverage or pay a penalty to the government. The PPACA includes multiple provisions that take effect over a period of years, including the expansion of Medicaid eligibility, the establishment of health insurance exchanges and the prohibition of health insurers from denying coverage due to pre-existing conditions.
A general term for care that doesn’t involve admission to a hospital as an inpatient. Visits to a doctor’s office are a type of ambulatory care.
A person or entity licensed, where required, and performing services within the scope of such licensure. Ancillary Providers include but are not limited to: Ambulance Service; Clinical Laboratory; Home Infusion Therapy Provider; Independent Diagnostic Testing Facility (IDTF); Suite infusion Therapy Provider; Suppliers.
All insurance issuers must have a standard internal appeal process and an external review process if a claim is denied.
Required approval from the health plan before a non-emergency hospital stay or outpatient procedure. Also referred to as pre-certification and certification.
When a provider bills you for the difference between the provider’s charge and the plan allowance. For example, if the provider’s charge is $100 and the plan allowance is $70, the provider may bill you for the remaining $30. Providers who are “in-network” may not balance bill you for covered services.
A person who is eligible to receive coverage under a particular health plan. Sometimes “beneficiary” is used for eligible dependents enrolled under a health plan.
The services or procedures covered by your health insurance plan.
The specific period of time during which charges for covered services must be incurred in order to be eligible for payment by the health plan. A charge is considered incurred on the date a member receives a service or supply for which the charge is made.
A plan that provides payments for covered services for covered individuals in return for a premium paid in advance (by the member, employer or both). Benefit plans typically include deductibles, maximums, copayments, coinsurances and exclusions and limitations.
A health care provider who coordinates care for those who are elderly, disabled or chronically ill. A care coordinator can provide services in a home or in a community facility.
The process of coordinating medical care provided to patients with specific diagnoses or those with high health care needs. These functions are performed by a case manager who can be a physician, nurse or social worker.
A type of coverage designed to protect you financially in the event of a major health event or emergency, such as a heart attack or accident. This type of insurance usually has a low monthly premium with a high deductible. You take on more out-of-pocket expenses in exchange for lower premiums. Catastrophic plans are typically for those who are single, under 30, have no ongoing medical issues and can pay large unexpected medical expenses to meet a high deductible in the event of an emergency. This type of plan may be available to cover family members if they are all under 30. A catastrophic plan also may cover individuals who have received a Certificate of Exemption based upon inability to afford coverage or who meet certain other categories of hardship.
A federal program that provides health coverage to families with incomes too high to qualify for Medicaid, but without the resources to afford private coverage. Signed into law in 1997, CHIP provides federal matching funds to states to provide this coverage.
The coordinated efforts of health care professionals to help patients with chronic diseases such as diabetes, high blood pressure, lupus and asthma to understand their condition and live with it successfully.
A statement sent to an insurance issuer that lists the treatment performed, the date of that treatment and an itemization of associated costs. Also serves as the basis for payment of benefits.
Your part of a medical bill that you pay after reaching your deductible. For example, if your medical bill for covered, in-network services is $100 and your coinsurance is 20%, you pay $20. The insurance company pays $80. See balance billing for details on out-of-network care.
A federal law that requires employers to offer continuous health care coverage on a temporary basis to employees and their dependents who would otherwise lose coverage due to termination of employment or other factors. Under the Affordable Coverage Act, individuals will be required to find replacement coverage or risk incurring a tax penalty once their COBRA coverage ends.
Research that compares health care options to determine the effectiveness, benefits and harms of different types of treatment. Information from CER can help you make an informed decision about which treatment is best for you.
Time period that runs from the effective date to the expiration date of the health insurance contract. Used primarily to measure and calculate when a member has met deductibles, out-of-pocket limits, etc.
Allows current Highmark members who are losing their coverage in a group program to convert to an individual or family plan without a lapse in coverage.
A provision in an insurance contract that applies when a person is covered by more than one insurance program. Requires that all insurance programs coordinate with each other in paying benefits, to eliminate duplication or overpayment.
A fixed, up-front dollar amount (for example, $25) that you pay each time you receive covered health care services. The amount can vary based on the type of health care service you receive, such as filling a prescription drug, seeing your doctor or visiting a specialist.
The share of costs covered by your insurance issuer for a covered service that you pay out of your own pocket. Remember that a “covered” service does not mean the insurance issuer pays the entire cost for that service—members often have a portion of “cost-sharing”. This term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.
These help lower the amount you might pay for out-of-pocket costs at the time you receive care. The government determines if you’re eligible for a cost-sharing reduction based on your household size and income. Many working families and individuals with modest incomes may be eligible for cost-sharing reductions. Cost-sharing reductions (CSRs) are only available for certain individual, qualified health plans purchased through the Health Insurance Marketplace.
The time period between the expiration of one policy and the commencement of another.
The time period during which you have health care coverage.
A service or supply that qualifies for coverage under a specified health insurance plan.
The dollar amount you must pay each benefit period (usually a year) for your health care expenses before your plan begins to pay for all or part of the remaining covered in-network services. For example, if you have a $500 network deductible, that’s the amount you will pay before your insurance plan will pay for all or part of the remaining covered in-network services. Not all benefits are subject to a deductible.
When services are not covered under your plan, the claim is denied. The plan explains why it did not pay the claim on the Explanation of Benefits (EOB).
A person covered under a health plan who is not the primary enrollee or policyholder, usually a spouse or child.
Lab work or tests ordered by a doctor or health care professional because of specific symptoms to determine a specific condition or disease, or for the purpose of routine screening. Examples include X-rays and blood tests.
A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.
A list of drugs your insurance plan covers. A drug’s formulary status may impact how much you pay for each drug.
Drugs on a formulary are typically grouped into tiers. The tier that your medication is in determines your portion of the drug cost. Depending on the medical and prescription plan you choose, the number of drug tiers may vary.
A term used to describe an individual who is eligible for Medicare and for some level of Medicaid benefits. Most dual eligibles qualify for full Medicaid benefits including nursing home services, and Medicaid pays their Medicare premiums and cost-sharing. For other duals, Medicaid provides Medicare Savings Programs through which enrollees receive assistance with Medicare premiums, deductibles and other cost-sharing requirements.
When a person has coverage for the same health services under more than one health benefits plan.
Equipment and supplies that are ordered by a health care provider for everyday or extended use, are primarily and customarily used to serve a productive medical purpose, and are generally not useful to a person in the absence of illness, injury or disease. Coverage for DME may include oxygen equipment, wheelchairs or crutches.
The date on which insurance benefits begin.
Computerized records of a patient’s medical history that may include information such as progress notes, problems, medications, vital signs, laboratory data and radiology reports. Because the information is stored electronically, it can be easily retrieved and shared across health care organizations.
Details contained in each health insurance plan that specify who qualifies for coverage under that plan.
A service or supply that qualifies for coverage under a specified health insurance plan.
An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Ambulance services for an emergency medical condition.
Emergency services you receive in an emergency room.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
A person who receives benefits under an insurance plan contract (also known as “member,” “insured,” “covered person,” or “beneficiary”).
A federal program, such as Medicare and Medicaid, for which people who meet eligibility criteria have a federal right to benefits.
A set of core benefits that all insurers will be required to include in qualified health insurance plans. The 10 categories of Essential Health Benefits (EHBs) include:
An approach to health care that focuses on the risks and benefits of treatments and diagnostic tests. This helps doctors predict whether a treatment will do more good than harm.
(The “Health Insurance Marketplace,” or sometimes called a “health insurance exchange.”) A system through which private insurance companies offer health insurance to smaller employers and individuals. Qualified health plans (QHPs) offered in the Health Insurance Marketplace (also called the “exchange”) will be sold and administered by private companies that meet standards established by the U.S. government. These insurers will offer a choice of different health plans that are required to provide the same essential health benefits. Insurers must provide clear information that helps consumers understand their options.
Services that your health insurance plan does not pay for or cover.
A health care plan which provides benefits when care is received from network providers, and for emergency care when received at either network or out-of-network providers.
Statement sent by a health plan that details the charges for the service(s) received, the covered service(s), the plan’s allowable charge(s) for the covered service(s), the amount the health plan pays for the service(s) and the amount(s) the member is responsible for paying.
A measure of income level issued annually by the Department of Health and Human Services. The FPL determines your eligibility for certain programs and benefits.
A traditional method of paying for medical services under which doctors and hospitals are paid for each service they provide, rather than a pre-negotiated amount for each patient. Bills are either paid by the patient, who then submits them to the insurance company, or are submitted by the provider to the patient’s insurance carrier for reimbursement.
A list of drugs your insurance plan covers. A drug’s formulary status may impact how much you pay for each drug.
A period of time during which a contract holder may examine a newly issued health insurance policy and surrender it in exchange for a full refund of premium if not satisfied for any reason.
A prescription drug that has the same active ingredient formula as a brand name drug. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs. Usually, generics cost less.
A specified period of time allowed after a premium payment is due during which payment will still be accepted without loss of coverage.
A complaint that you communicate to your health insurance plan.
Health insurance that is offered to a group of people, such as employees of a company. The majority of Americans have group health insurance through their employer or their spouse’s employer.
Health care services that promote the restoration, maintenance or improvement in the level of function following disease, illness or injury, including therapies to achieve functions or skills never acquired due to congenital and developmental anomalies. These services may include physical and occupational therapy, speech-language pathology and other services in a variety of inpatient and/or outpatient settings.
For more information on Health Care Reform or the Patient Protection and Affordable Care Act, please refer to Insurance Information You Need to KnowInsurance Information You Need to Know.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
A system through which insurers offer health insurance to smaller employers and individuals. Qualified health plans (QHPs) offered in the Health Insurance Marketplace (also called the “exchange”) will be sold and administered by private companies that meet standards established by the U.S. government. These insurers will offer a choice of different health plans that are required to provide the same essential health benefits. Insurers must provide clear information that helps consumers understand their options.
A federal law that, among other things, protects people who change jobs, are self-employed or who have pre-existing medical conditions. HIPAA helps health insurance plan members to continue health coverage and to transition between individual and group health coverage.
An organization that provides managed care through a network of doctors, hospitals and other providers on a prepaid basis. Unlike traditional health insurance, an HMO offers care through doctors and other health care professionals and organizations that have contracted to treat patients according to the HMO’s guidelines in exchange for a steady stream of customers.
A health savings account (HSA) is a tax-sheltered account that is paired with a federally qualified high-deductible health plan. Individuals have the option of opening an HSA and can decide how much to contribute up to the allowed amount and can make investment choices. Employers may also choose to contribute to the HSA account. HSA dollars can carry over from year to year and can be transferred if a consumer changes health plans. Participants can use funds on a wide range of medical services and products, using account funds to pay for everything from acupuncture to dental fees to chiropractic services.
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness, and for their families.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be considered outpatient care.
Care in a hospital that usually does not require an overnight stay.
The technique and process used to create images of the human body (or parts and function thereof) for clinical purposes.
A vaccination that induces immunity. A recommended schedule of immunizations for infants and young children include vaccines against diseases and conditions such as polio, tetanus, measles, mumps, rubella, etc.
The market where individuals who do not have group (usually employer-based) coverage purchase private health insurance. This market is also referred to as the “non-group” market.
A key part of the Affordable Care Act, effective in 2014, includes the “individual mandate.” This mandate is another way of saying that most people living in the U.S. who don’t receive health insurance from their employer will be legally required to have “minimum essential” health insurance coverage beginning in 2014, or possibly pay a tax penalty to the government.
A health insurance policy sold to an individual directly, not health coverage offered through an employer-sponsored plan. An individual plan can cover the individual and/or dependents.
Your part of a medical bill that you pay after reaching your deductible. For example, if your medical bill for covered, in-network services is $100 and your coinsurance is 20%, you pay $20. The insurance company pays $80.
A fixed, up-front dollar amount (for example, $25) that you pay each time you receive covered health care services. The amount can vary based on the type of health care service you receive, such as filling a prescription drug, seeing your doctor or visiting a specialist. After paying your copay, your insurance company will usually pay the remainder of your bill for covered in-network care.
Highmark contracts with doctors, hospitals, clinics, labs and other providers to provide health services to its members. These health care providers form a Highmark network. You usually pay less when you use network health care providers and not “out-of-network” providers with whom Highmark does not have a contract.
A patient who is admitted to a hospital, extended care facility, nursing home or other similar health care institution that requires at least one overnight stay.
Care given to a patient who is admitted to a hospital, extended care facility, nursing home or other similar health care institution that requires at least one overnight stay.
An organization that provides health care services through a network of organizations under a parent holding company. The network could include physicians and/or hospitals. Highmark is an IDN.
An obligation for a specified amount or action.
Services that include those needed by people to live independently in the community, such as home health and personal care, as well as services provided in institutional settings such as nursing homes. Medicaid is the primary payer for long-term care. Many of these services are not always covered by Medicare or private insurance.
Medicine prescribed for a chronic condition that must be taken on a regular, recurring basis—usually six months or longer.
A health delivery system that seeks to control access to and usage of health care services both to limit health care costs and to improve the quality of the care provided. Managed care arrangements typically rely on a primary care physician to act as a “gatekeeper” and manage the care a patient receives.
A health insurance plan that requires you to see doctors and hospitals that have a contract with the managed care provider.
An organization generally made up of physicians, hospitals and other providers that offers a wide variety of managed health care services to enrolled members. The goal of an MCO is to deliver quality care while managing costs through preventive medicine and patient education.
Covers physician and hospital services for mother and baby from time of pregnancy through post-partum care.
A federal entitlement program that provides health and long-term care coverage to certain categories of low-income Americans. States design their own Medicaid programs within broad federal guidelines. Medicaid fills gaps in the health insurance system, finances long-term care coverage and helps sustain providers who serve the uninsured.
A patient-focused approach to health care built on a partnership among providers, patients and their families. It ensures that patients receive the education and support they need to make informed decisions and participate in their own care.
The Medical Loss Ratio, or MLR, is a provision of the Affordable Care Act that generally requires insurance companies to use at least 80 cents out of every dollar in premiums they receive to pay for medical claims and activities that improve care quality.
Health care services that a physician exercising prudent clinical judgment would provide to a patient in order to evaluate, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
A federal entitlement program that provides health insurance coverage to 45 million people including people age 65 and older, and younger people with permanent disabilities, end-stage renal disease and Lou Gehrig’s disease.
Health care services used to treat mental illness. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors.
Minimal essential coverage is the minimum level of benefits that must be included in a health insurance plan in order for you to be considered insured and avoid paying a tax penalty. In order to meet these standards, all qualified health plans (QHPs) must include 10 core Essential Health Benefits (EHBs). For questions about your specific coverage and whether it meets minimal essential coverage standards, contact your health insurance issuer.
The income tax system used under the Affordable Care Act to determine eligibility for Medicaid and for tax credits available to people buying insurance in the Health Insurance Marketplace (the “exchange”). The income calculations will take into account family size and income from all family members.
The dollar amount paid to the health insurance issuer each month to maintain coverage.
Doctors, hospitals, clinics, labs, and other providers that a health insurance insurer has contracted with to provide health care services to its members. You usually pay less when you use health care providers that are "in-network." You may pay extra if you see a health care provider who is "out-of-network" (or "non-network").
A doctor, hospital, clinic, lab or other provider with whom an insurance company has contracted with as a participant in a network to provide health services to its members.
Open enrollment is a time period during which you can either renew your current health insurance or plan or switch to a new one. These options are generally available once a year.
A brief description of proposed insurance coverage, premiums, benefits, limitations and exclusions. It is a summary only and encourages the applicant to read the actual policy or certificate carefully.
The percent you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance plan as a network participant. Out-of-network coinsurance usually costs you more than in-network coinsurance.
A fixed amount you pay for covered health care services from providers who do not contract with your health insurance plan as a network participant. Out-of-network co-payments are usually more than in-network co-payments.
Highmark contracts with doctors, hospitals, clinics, labs and other providers to provide health services to its members as a network participant. (In certain circumstances, a plan may have a contract with an out-of-network provider.) These providers form a network. Health care providers with whom Highmark does not have a contract are considered to be “out of network.” You usually pay more when you use “out-of-network” health care providers.
Costs not covered by the health insurance plan, such as co-payments, coinsurance, deductibles and fees, that the covered person pays personally when receiving health services or prescriptions.
The highest amount of deductible, copayment and coinsurance expenses you will need to pay each benefit period (usually a year) for covered in-network care before your insurance company pays 100%. For example, if your out-of-pocket maximum is $2000, once you have paid $2000 the insurance issuer pays for 100% of the plan allowance for covered in-network care. This does not include any services not covered by your plan.
Any health care service provided to a patient who is not admitted to a hospital. An outpatient procedure can take place in a doctor’s office, clinic, the home or a hospital outpatient department.
Medical care that focuses on providing patients with relief from the symptoms, pain and stress of a serious illness.
Any doctor, hospital, clinic, lab or other provider in a plan’s network. When members receive care from a participating health care professional, they usually pay less for services.
(Also called the “Affordable Care Act.”) On March 23, 2010, President Obama signed comprehensive health reform legislation into law known as the Patient Protection and Affordable Care Act (PPACA). “Obamacare” is another term people use when they talk about this law. The PPACA includes changes that aimed to expand access to coverage, control health care costs and improve health care delivery for U.S. citizens and legal residents. Most U.S. citizens and legal residents are now required to have health insurance coverage or pay a penalty to the government. The PPACA includes multiple provisions that take effect over a period of years, including the expansion of Medicaid eligibility, the establishment of health insurance exchanges and the prohibition of health insurers from denying coverage due to pre-existing conditions.
Health care services provided by a licensed medical physician: an M.D (Medical Doctor) or a D.O. (Doctor of Osteopathic Medicine).
The amount used to determine payment by the insurance issuer for covered health care services. Plan Allowance is based on the type of Provider who renders the services, or as required by law. If your provider charges more than the allowed amount, you may have to pay the difference.
Services not covered by an insurance plan.
Rules allowing people to obtain coverage as they move from job to job or in and out of employment. Individuals changing jobs are guaranteed coverage with the new employer. In addition, insurers must waive any pre-existing condition exclusions for individuals who were previously covered within a specified time period.
A decision by your health insurer or plan that a health care service, treatment plan, prescription or durable medical equipment is medically necessary. Also referred to as “prior authorization,” “prior approval” or “precertification.” Your health insurance plan may require preauthorization for certain services before you receive them. Preauthorization is not a promise that your health insurance plan will cover the cost.
(Also known as a “formulary.”) A list of drugs your insurance plan covers. A drug’s formulary status may impact how much you pay for each drug.
A provider who has a contract with your health insurance plan to provide services to you at a discount. Your health insurance plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurance plan, but the discount may not be as great, and you may have to pay more.
In this type of health insurance plan, you pay less if you use providers in the plan’s network. You can also use providers outside of the plan’s network, but they will generally have higher out-of-pocket costs.
The amount of money you pay each month for your health insurance. You must pay this dollar amount every month—even if you don’t use services that month.
A fixed amount of money or a designated percentage of the premium cost that is provided to help people purchase health coverage. Premium subsidies are usually provided on a sliding scale based on an individual’s or family’s income.
Drugs and medications that by law require a prescription.
Screenings or routine services that may prevent or detect problems before they advance. For example, child wellness visits are preventive.
A Primary Care Physician (PCP) (also referred to as Primary Care Provider) is the medical professional who provides a patient’s care and helps them access a range of health services. This could be a doctor, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law.
A Primary Care Provider (PCP) (also referred to as Primary Care Physician) is the doctor who provides most of your basic care, such as yearly preventive visits and screenings. In most cases, your PCP will coordinate your care with specialists, health care facilities and other providers.
An M.D (Medical Doctor), D.O. (Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Doctors, hospitals, clinics, labs, and other providers that a health insurance issuer has contracted with to provide services to its members. You usually pay less when you use health care providers that are “in-network.” You may pay extra if you see a health care provider who is “out-of-network” (or “non-network”).
The total payment that a provider, hospital or community health center receives when they provide medical services to a patient. Providers are compensated for patient care using a set of defined rates based on illness category and the type of service administered.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
A physician’s medical order for services or consultations to be provided by a specialist.
Continued coverage of a policy beyond its original term, with the acceptance of premiums by the insurer for a new policy term.
A periodic visit with a provider such as a doctor or nurse practitioner. This type of service can also be referred to as preventive care.
A health benefit in which an employer funds the cost of claims. To protect the company again excessive claims, the employer may buy what is known as stop-loss coverage. A growing number of firms consider such plans to be low-cost alternatives to conventional coverage.
Services which have been ordered by and are under the direction of a Physician or PCP, and are provided either directly by or under the supervision of a health care provider with the treatment described and documented in the patient’s medical records.
Federal and state Health Insurance Marketplace programs (“exchanges”) that are open to small businesses. The SHOP Marketplace is open to employers with 50 or fewer full-time-equivalent employees (FTEs).
Firms with 1-50 employees can purchase health insurance for their employees through this market, which is regulated by states.
A physician, other than a Primary Care Physician (PCP), focused on a specific area of medicine or surgery.
A therapeutic intervention performed on the spine.
The person in whose name an insurance policy is registered.
An easy-to-understand summary that uses plain language to explain a health plan’s benefits and coverage.
See Advance Premium Tax Credit (APTC)
(Also known as the “expiration date.”) The date on which an insurance policy expires or the date that an individual ceases to be eligible for plan benefits.
Specialized consultative care, usually through a referral from primary or secondary medical care personnel. Care is delivered by specialists working in a center that has personnel and facilities for special investigation and treatment.
The following Services when ordered to promote a person’s recovery: chemotherapy; dialysis treatments; infusion therapy; pulmonary therapy; radiation therapy; and respiratory therapy.
A medical service that a health insurance plan does not cover.
Care for an illness, injury or condition serious enough that it requires care right away, but not so severe as to require emergency room care.
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
A physician’s office visit which is not prompted by sickness or injury.
Programs that promote good health and/or disease prevention (e.g., fitness programs, health screenings, health coaching).