Intro to Health Insurance

Introduction to Health Insurance

UPMC Health Plan Member Services Training

Learning Objectives

This module is designed to give you an overview of how health insurance works. We’ll review insurance terminology and learn about the products that the UPMC Insurance Services Division offers. By the completion of this module, you will:

• Understand the concept of health insurance and how it works
• Understand how the Health Plan operates
• Understand insurance terms, their definitions, and how to use them appropriately
• Get an overview of all the UPMC Health Plan products and understand the differences between all lines of business

Chapter 1: How Health Insurance Works

Insurance can be confusing and even overwhelming, but don’t panic! As we explore insurance terminology and learn about Health Plan operations, please feel free to ask questions! We want to ensure a full understanding and we don’t mind slowing down to review information!

What is Health Insurance?

Let’s see what we already know! Take 5 minutes to write down as much as you can (definitions, key words, etc.) about the following things – but there’s a catch: No Google!

Deductible Copayment Subscriber Dependent Medicare PCP Specialist

Claim Referral Premium Effective Date Explanation of Benefits Network Provider

What is Health Insurance?

What is Health Insurance?

Health insurance is a service-based product that provides financial protection against losses incurred due to illness or injury. More simply – Health Insurance helps cover the cost of medical bills. Health insurance works similarly to other types of insurance.

• Life insurance protects family members from losses in the event of death.
• Car insurance protects drivers in the event of an auto accident.

Health insurance customers are known as members. Members are part of groups.

What is Group Insurance?

• Group insurance is when multiple people purchase coverage together, as a group.
• Their insurance premium (the fee paid to have insurance coverage), is part of a larger pool of money. We will discuss how group insurance premiums work later in this section.
• Employer group coverage is when the employer “owns” the policy and allows their employees to sign up for their group-sponsored plan.
• Eligibility is the defined as the different conditions that determine of someone is “allowed” or “able” to be covered under an insurance plan.

What is Group Insurance?

• If you’ve ever had roommates, then you already understand the concept of group coverage and how it works!
• Think about Friends: Rachel, Monica & Phoebe share and apartment. They divide the rent and utilities 3 ways, regardless of how much time each person spends in the apartment and how much of the utilities they use.
• Monica stays at Chandler’s apartment 3 nights per week
• Rachel washes her hair twice a day
• Phoebe works from home and uses electricity all day

Group insurance coverage means that a group of people are buying insurance together and share the costs, regardless of services used individually.

Employer-Sponsored Health Benefits

• The Affordable Care Act mandated that organizations with 50 or more full-time equivalent employees must offer employees and their dependents affordable health insurance or pay a penalty.
• Employers with 49 employees or less do not have to offer group insurance coverage to employees, but they receive tax credits if they do.
• If an employer doesn’t provide coverage for employees, or provides coverage that is unaffordable, they must make a per-employee, per-month “Employer Shared Responsibility Payment.”
• Usually, if you have employer-sponsored group insurance, your insurance premium comes out of your paycheck.
• Medicare Advantage members, though retired, can also have employer plans. There are two kinds:
• Contributory groups, where the employer group subsidizes all or a portion of the monthly premium, and the Health Plan bills the employer group for the premium.
• Sponsorship groups, where the employer group sponsors a plan, and the retiree pays the monthly premium directly to the Health Plan.

What are Dependents?

• A dependent is anyone who can be added to a policy holder’s insurance plan based upon certain criteria. Dependents can be:
• Children, step-children, or adopted children, until they turn 26 years old (regardless of marital status)
• Spouses
• Qualified domestic partners
• Disabled/handicapped children beyond the age of 26 (Annual re-certification is required.)

Plans Without Dependents

• Some Health Plans, like Medicare, Medicaid, and CHIP (Pennsylvania’s Children’s Health Insurance Program) do not have dependents.
• For each of these kinds of plans, each member has their own plan.
• For example:
• A husband and wife on a Medicare Advantage plan will have two different policies.
• Two siblings on CHIP will have two different policies.
• Domestic partners on Medicaid will have two different policies.

Member, Subscriber, Dependents

• Subscriber or Policy Holder:
• The person who has signed up for and enrolled in an insurance policy
• For Medicare, Medicaid, and CHIP, member=subscriber
• Subscriber Unit or Dependents:
• Family members on the same insurance policy
• Commercial, Ancillary, and Marketplace plans can have subscriber units

Mei has insurance through her employer, so she is the subscriber or policy holder.

Mei’s husband and children are her dependents, or part of the subscriber unit.

Policy Number, Member ID Number, and ID Cards

• Each UPMC Health Plan member has a unique ID number. The ID number is made up of the policy number (first nine digits) and the person code or person number (last two digits).
• In our example, Mei’s ID number is 12345678901.
• Her husband’s member ID number is 12345678902 and her children’s are 12345678903 and 12345678904.

The member ID card also has other information, like the member’s PCP (Primary Care Physician), Rx and copay information

Policy Number, Member ID Number, and ID Cards

• Each UPMC Health Plan member has a unique ID number. The ID number is made up of the policy number (first nine digits) and the person code or person number (last two digits).
• George and Mary (below) are married and are both retired. They have UPMC for Life Medicare Advantage plans.
• George’s ID number is 12121212101. Mary’s ID number is 56565656501.

UPMC for Life Medicare member ID numbers will always end in 01. Medicare plans cannot have dependents.

The 1st nine digits on the member ID card are the policy number, while the last 2 digits are a person code or person number, used to identify which person on the plan is using benefits

This is a view of the card for participants with ONLY our CHC plan.

This is the card for Members with our UPMC for Life Dual plan as well as CHC.

Types of Health Plans

Types of Health Plans

HMO Health Maintenance Organization Requires the insured member to use only the insurance company’s network of doctors and hospitals. Requires the insurance member to have a dedicated primary care physician (PCP). Preventive services covered 100%

PPO Preferred Provider Organization It’s “preferred” that the insurance member uses the insurance company’s network of doctors and hospitals, but they can also use doctors and hospitals that are not part in the network. Out of network care has higher cost sharing Does not require a dedicated PCP Preventive services covered 100%

EPO Exclusive Provider Organization PCP is not required to coordinate care. Requires the insured member to use only the insurance company’s network of doctors and hospitals. Preventive services covered 100%

HDHP High Deductible Health Plan Usually comes along with an HSA (Health Savings Account) Preventive services covered 100%

Health Plan Networks

• UPMC Health Plan has several networks that vary by product and plan. Having multiple network options allows for more choice and the ability to save money.

HMO and EPO plans may have a lower monthly premiums and lower costs for members. This is because the HMO and EPO plans require the member to use the Health Plan’s approved network of providers. The Health Plan pays their participating providers less. The savings can be passed on to the members. For example: UPMC Health Plan is contracted with UPMC Mercy Hospital. If I have a surgery at UPMC Mercy, it will cost my insurance less than if I have a surgery at a non-contracted, non-participating hospital, like Johns Hopkins.

Health Plan Networks

• Most of our members are covered for emergency services out of network. Some members also have Out-of-Area plans that give them full-time access to two partner networks that UPMC Health Plan contracts with, outside of the UPMC Health Plan Service Network.
• All UPMC for Life Medicare members on an HMO or PPO plan are covered for emergency services anywhere. Members on these plans also have a value-added service with their plans called Assist America. Assist America can help them find care when they are 100 miles or more away from home, but it is not mandatory for ER or Urgent Care visits.
• UPMC for Life Medicare Individual HMO (and some employer-sponsored retiree HMO plans) offer a Travel benefit (utilized primarily by PA residents who like to head South for warmer weather in the winter). We will learn more about this in our Product Training. There is no extra charge for Assist America or the Travel Benefit.

What About Costs?

Out of Pocket Expenses

• Every Health Plan has an out-of-pocket maximum (OOP max).
• The OOP max is the most money a member pays in a given year for covered services.
• Once the OOP max has been met, covered services are paid for 100% by the Health Plan, with no cost to the member.
• The out-of-pocket maximum is not a dollar amount that must be paid per year. It is in place as a protection – if the member becomes very ill or requires a lot of medical services, the most they will pay is $_____.00.
• Example: My Health Plan has a $5,000.00 out-of-pocket maximum. I had a skiing accident and was in the hospital for two weeks. I had many MRIs and CT scans, as well as medications and care for broken bones. When I was released, I had home nursing care for two months. I had extensive physical therapy and many follow-up appointments to make sure that I was healing properly. Even if my hospital and follow-up care cost $1 million, I will pay a maximum of $5,000.00.

Out of Pocket Expenses: Deductible

• A deductible is the specified amount of money that a member must pay towards their medical expenses before an insurance company will pay anything for care.
• Example: I am having a baby. My Health Plan has a $500.00 deductible for any inpatient hospital care. I deliver my baby and two weeks later, I receive a bill from my Health Plan. The total charges were around $20,000.00. My bill is for $500.00, because that is my deductible. My Health Plan paid the rest.
• I have now met my deductible for the year. This does not necessarily mean that I will pay $0.00 for all of my services until the next year, though. Keep in mind, deductible and OOP max are not the same thing!
• Deductibles on health insurance plans work like deductibles on car insurance plans.
• Example: You get into a minor car accident. Your auto insurance policy has a $1,000.00 deductible. This means you must pay $1,000.00 before your insurance will pay for any of the repairs on your car.

Out of Pocket Expenses: Coinsurance, Copay

• Coinsurance (sometimes abbreviated “coins.”) is a percentage amount that the member pays for covered services, while the Health Plan pays the remainder.
• Example: You’re injured playing a friendly game of football. You require crutches. The crutches cost $100.00. Your Health Plan has a 20% coinsurance for all medical equipment. So, you pay $20.00 for the crutches, and your Health Plan pays $80.00.
• A copay is a fixed amount someone pays for a service, paid each time the service is performed.
• Example: Your Health Plan has a $40.00 copay for a specialist’s office visit. You go to the dermatologist. You must pay $40.00. Whether the services performed by the doctor cost $50.00 or $500.00, you pay $40.00, because that is the copay set by your Health Plan.

Out of Pocket Expenses Review

• Deductibles, copays, and coinsurance are all kinds of out-of-pocket (OOP) expenses.
• Health Insurance policies can differ greatly! Some may have deductibles, some may have copays, some may have coinsurance, some may have all of these, and some may have none of these.
• Health Plans decide on the dollar and percentage amounts for each policy’s OOP max, deductible/s, copays, and coinsurances. However, the amounts are paid directly to the provider/s of care, not back to the Health Plan.
• Example: I have a UPMC Health Plan policy. On the policy, my copay for Urgent Care is $50.00. I get the flu and go to Med Express. I pay $50.00 to Med Express for my care. I do not pay UPMC Health Plan.
• Health Plans are responsible for processing claims (a claim is a request for payment of covered medical expense which is sent to an insurance company). Health Plans do not collect payment for services rendered to members/patients.
• Example: Members cannot pay UPMC Health Plan for an x-ray they received at UPMC Presbyterian Hospital.

Claims Payment (A Step-By-Step Example)

1. A member has an appointment with her cardiologist, Dr. Jones, to review the results of a recent stress test.
2. Dr. Jones’ office submits a claim to UPMC Health Plan. There are two services billed on the claim – an office visit (for $100.00) and a chest x-ray (for $50.00).
3. UPMC Health Plan processes the claim according to the member’s plan benefits. On the member’s plan, she has a specialist’s visit copay of $30.00, and an x-ray copay of $10.00. UPMC Health Plan pays $70.00 for the office visit and $40.00 for the x-ray to Dr. Jones. (Note: payments made by the Health Plan to in-network, participating providers for covered services are at a discounted, contracted rate. We’ll learn more about contracted rates in our in-depth Claims Training.)
4. The Health Plan sends Dr. Jones an EOP stating that the member should be billed for $40.00.
5. The Health Plan sends the member an EOB showing what was paid to Dr. Jones and showing that her share will be $40.00.
6. Dr. Jones sends the member a bill for $40.00.
7. The member sends Dr. Jones’ office a check for $40.00.

Chapter 2: UPMC Insurance Services Division

UPMC Health Plan is a division of UPMC Insurance Services, an independent company that is closely affiliated with both the UPMC Health System and the University Of Pittsburgh.

In this module we will introduce core concepts that will be revisited throughout training, including:

• How insurance and managed care work
• Insurance terms
• UPMC’s integrated care model
• An overview of UPMC Health Plan products and services

Product Types

• UPMC Health Plan has two main product types:
• Government Products
• UPMC for Life- Medicare
• UPMC for Life Complete Care- Medicare and Medicaid
• UPMC for Kids- CHIP
• UPMC for You- Medicaid
• UPMC Community Health Choices - Medicaid
• Commercial Products
• UPMC Health Plan for Businesses
• UPMC Marketplace

What is Medicare?

What is Medicare Part D?

UPMC for Life

UPMC for Life is a Medicare Advantage Plan owned by UPMC.

• UPMC for Life members have in-network access to UPMC doctors and hospitals, plus many other community providers.
• UPMC for Life members retain their Original Medicare benefits, plus get some extra coverage for things like routine dental and vision care, fitness club memberships, and travel benefits.
• UPMC for Life members also have access to the UPMC MyHealth 24/7 Nurse Line, UPMC Anywhere Care, and UPMC MyHealth OnLine.

What is Medicare?

• Medicare is a federal health insurance program.
• To qualify, you must be a US citizen or legal resident who has lived in the US for five consecutive years, and you must also:
• Be 65 years old or older, or
• Be under age 65 with certain disabilities

UPMC AnywhereCare

UPMC for Life Complete Care

This plan is for those who are eligible for Medicare and Medical Assistance. UPMC for Life Complete Care provides access to 8,700 UPMC doctors and 87 hospitals, as well as urgent care centers, community hospitals, and specialty care centers. No referrals required. UPMC for Life Complete Care offers enhanced dental and vision benefits for dual eligible beneficiaries, along with extra benefits and services that help manage overall health and wellness. This plan can also help coordinate Medicare and Medical Assistance services.

UPMC for Kids

With UPMC for Kids™ no child needs to be without exceptional health insurance. Regardless of family income, children under the age of 19 qualify for the Pennsylvania Children’s Health Insurance Program (CHIP) if they are not covered by private health insurance and are not eligible for or enrolled in Medical Assistance. In addition to a broad array of medical, dental, and vision care benefits, UPMC for Kids covers nutritional counseling, tobacco cessation counseling, and has Web-based tools and resources.

What is the UPMC for Kids Service Area? We serve 57 of the 67 counties in Pennsylvania – those not serviced are: Bucks, Carbon, Columbia, Delaware, Monroe, Montgomery, Montour, Northumberland, Philadelphia, and Pike.

UPMC for You

UPMC for You helps members stay healthy and get treatment for any health problems. Members have comprehensive benefits like coverage for doctor visits, immunizations, diagnostic testing, prescription medications, dental and vision care, emergency care, mental health care, hospital care, home health care, maternity care, and much more! UPMC for You also offers programs for asthma, diabetes, COPD, depression and heart disease.

UPMC for You manages members’ Medicaid. UPMC for You is continually ranked as one of the top Medical Assistance plans in PA for the last 11 years per the National Committee for Quality Assurance (NCQA). UPMC for You members can visit some of the best doctors and hospitals in Pennsylvania –the network includes both UPMC and community providers, totaling more than 86 hospitals and more than 10,000 physicians.

What is Medicaid?

• Medicaid in the United States is a joint federal and state program that helps with medical costs for some people with limited income and resources.
• Medicaid also offers benefits not normally covered by Medicare, like nursing home care and personal care services.
• Enrollment is through the PA Department of Human Services (formerly known as the Department Of Public Welfare).

UPMC Community HealthChoices (CHC)

• What is CHC?
• CHC is the Department of Human Services’ (DHS) new program that will allow managed care organizations (MCOs) to coordinate medical care and long-term services and supports (LTSS) for individuals who qualify for Medical Assistance and also qualify for Medicare or require a nursing facility level of care.
• UPMC Community HealthChoices is an MCO selected by DHS to provide this program in Pennsylvania.
• What is LTSS?
• Long-term services and supports (LTSS) helps individuals live as independently as possible. LTSS is either provided in a nursing facility or in a person’s home. It may include assistance with activities such as bathing, dressing, preparing meals, and taking medications. Services may also include in-home nursing care, therapy, nonmedical transportation, and career services, as well as home and vehicle modifications. The type of service and setting is based on each person’s needs and preferences.
• What services will CHC cover?
• If members are dual eligible for Medicare and Medicaid, their current Medicare benefits will not change or be affected by CHC. Their CHC MCO will become the secondary Medicaid payer.
• CHC will cover the same physical health benefits currently available through the Medicaid Adult Benefit Package.

UPMC Health PlanCommercial Insurance

Providing employees with high-quality coverage at a cost they can afford can be a challenge. When employers partner with UPMC Health Plan – regardless of their company’s size – they have access to a variety of plans at affordable rates. Our innovative plans offer superior health employers will appreciate.

Self Assure UPMC Health Plan is now providing an administrative services only plan to mid-market organizations. In the past, these kinds of plans have been available only to large companies, but now, mid-sized companies can take advantage of the benefits as well... including a large choice of plan designs, and competitive stop loss rates. UPMC HealthyU Employers are increasingly focused on the health and productivity of their employees as an essential business investment. Employers also need a cost-effective solution to the rising cost of health care. By combining a rich benefit plan with a healthy living incentive program, UPMC HealthyU is the solution to both. UPMC Business Advantage and UPMC Small Business Advantage Whether a company has two employees or 20,000, they all want the same thing – affordability, customer service they can count on, robust benefits, and plenty of value-added services. And with a group retention rate of 94.4% as of June 2013, it’s clear that we deliver what our employer groups want. UPMC MyCare Advantage™ UPMC MyCareAdvantage™ is a tiered network plan for employer groups in northwestern Pennsylvania. The plan provides employees with the same type of coverage as other UPMC Health Plan offerings – but at a lower premium and with lower out-of-pocket costs when they choose quality hospitals in the 10-county MyCare Advantage network.

UPMC Health PlanAncillary Services

The Ancillary Services team provides customer service and support for a specific group of commercial products and services employer groups can elect to offer to their employees, such as:

• University of Pittsburgh
• Flexible spending accounts and health savings accounts
• Retiree benefits
• COBRA benefits
• UPMC Dental Advantage
• UPMC Vision Advantage
• Ancillary - 673 6014

Note: The UPMC for Life team handles service and support for some retiree benefits, UPMC Dental Advantage and UPMC Vision Advantage.

UPMC Health PlanMarketplace Insurance

Like shopping in an open-air market, the Marketplace is designed to help people compare services and choose the one they think is best. The Marketplace allows people needing to purchase insurance coverage the ability to compare plans and prices, just like you would compare two similar items at the grocery store.

Marketplace plans are divided into the following: On Exchange Individual coverage purchased through healthcare.gov to qualify for tax credits and subsidies. Off Exchange Generally, these are the same plans that are available on healthcare.gov but are purchased direct from UPMC Health Plan from people who do not qualify for a subsidy or tax credit.

• There are four tiers of Qualified Health Plans available on the Exchange. Each tier offers better benefits and less cost sharing.

HEALTH CARE REFORM - OBAMACARE - THE AFFORDABLE CARE ACT (ACA) Though the names have changed since the Act was signed into law in March 2010, certain principles remain the same. The ACA aims to make health insurance — and health care — accessible to more Americans. Marketplace insurance covers essential health benefits, preventive services at no cost, and expanded access to coverage.

UPMC Connect Sales & Service Centers

Members and non-members can visit a UPMC Health Plan Connect Service and Sales Center at a shopping mall near them to:

• Make monthly premium payments.
• Better understand current coverage and benefits.
• Get help with billing and claims questions.
• Locate participating providers.
• Speak one-on-one with a service and sales associate about plan options.
• See if you they for a federal subsidy.
• Enroll their children in a Children’s Health Insurance Program (CHIP) plan.
• Get help with Medicare eligibility and enrollment.
• Discover what’s included with UPMC Health Plan coverage.

Locations:

• Logan Valley Mall, Altoona
• Loyal Plaza Shopping Center, Williamsport
• Millcreek Mall, Erie
• Royal Oak Shopping Center, Monroeville
• Ross Park Mall, Pittsburgh
• South Hills Village, Pittsburgh
• The Mall at Robinson, Pittsburgh
• Capital City Mall, Camp Hill
• The Village at Eastside, Pittsburgh

Evolent Health

UPMC Health Plan began a joint venture in 2012 with Evolent Health to sell administration services and the UPMC care model to third parties. UPMC Health Plan is a third-party administrator, or TPA, of health insurance products for other companies. Basically, UPMC Health Plan is rebranded to offer a custom branded product to clients. The client pays UPMC a fee for administrating customer service, benefits administration, claims processing & payment, and other functions while assuming all financial risk just like a fully insured group would.

Managed Care Model

Managed care is an approach to healthcare intended to streamline services and provide quality, cost-effective healthcare. Through supervision, monitoring, and advising, managed care programs seek to ensure a certain standard of care. To keep costs low, healthcare companies contract with specific doctors who make up a network. Contracted, network providers agree to accept a lower fee for a service. They can accept lesser payments from members and Health Plans because, because of being in-network, they get more business. Some plans do not allow members to go outside of their network at all. If out-of-network care is allowed, members and Health Plans will pay more to these non-contracted providers. In the interest of preventing members from obtaining unnecessary services, many managed care plans require members to get approval before receiving certain services. Establishing member cost-sharing for services also saves money - members will have to pay for their share of those services. Additionally, managed care plans assist members in staying healthy and focus on preventive care. This cuts costs in the long run for Health Plans and members and can help detect problems early.

Plan Year

• A Plan Year is the year in which a plan is valid and gives us the date on which a new deductible or out-of-pocket maximum period begins and ends.
• Most plans, including UPMC for Life Medicare Advantage plans, begin on January 1st and end on December 31st.
• There are exceptions:
• Commercial groups can begin coverage any month of the year, which would start their 12-month plan year.
• CHIP plans begin on August 1st.
• Medicaid plans begin on July 1st.
• Some things reset at the start of a new plan year:
• Deductible
• Out of pocket maximum
• Initial coverage limit (Medicare Part D)
• Some things may reset at the start of a new plan year:
• Services such as routine chiropractic care may only be covered for 10 visits per year.
• Some things do not reset at the start of a new plan year:
• Anything on a “rolling calendar” will not reset at the beginning of a new plan year.
• Ex: Vision benefits are listed as available “every 24 months on a rolling calendar since your last date of service.” This means that 24 months must pass before the benefit renews., regardless of time of year.

Open Enrollment Periods

• Generally, members can only enroll into, disenroll from, or change plans during certain times.
• For Commercial plans, coverage usually begins/ends the month that your employment begins/ends. Changes can only be made during the open enrollment periods set by your employer and health insurance company, usually about 10 weeks before the date your plan is set to end or rollover.
• There’s no limited enrollment period for Medicaid or CHIP. If you qualify, coverage can begin immediately, any time of year.
• Marketplace plans have an open enrollment period that is set across the board for all insurance carriers but can vary from year to year. For coverage effective January 1, 2018, Marketplace open enrollment was from November 1-December 15, 2017.
• For Medicare plans, the Annual Enrollment Period (AEP) is always October 15-December 7 of each year. This is when existing Medicare beneficiaries can enroll into, disenroll from, or make changes to their existing Medicare plans.

Medicare’s Initial Enrollment Period

• Initial enrollment into Medicare is ongoing year-round and depends on a beneficiary’s birthday. We will talk more about Medicare enrollment in future trainings, but here’s what you need to know for now:

Qualifying Life Events or Special Enrollment Periods

Q: What is a qualifying life event? A: A circumstance that makes a member eligible to change plans outside of the open enrollment period.

• If a member wishes to change plans outside of open enrollment, they must have a qualifying life event to be able to do so.
• For Medicare, qualifying life events are called “special enrollment periods,” and there are many of them.

Some examples of qualifying life events:

What is COBRA Coverage?

• COBRA allows workers and their families to continue their group benefits for limited periods of time after leaving their employer or losing their eligibility status.
• In general, COBRA benefits are required by employer-sponsored health plans that are offered to employees in companies with 20 or more full-time workers.
• However, once the employees leaves the company and elects COBRA benefits, they are responsible for paying the entire premium, including the amount that was previously paid by the employer. In addition, the employee may also have to pay up to two percent in administration fees to continue the policy.
• COBRA can last for up to 18 months for employees and their dependents when workers would otherwise lose coverage because of a termination or reduction in hours.
• COBRA can last for up to 29 months for employees who are determined to have been disabled at any time during the first 60 days of COBRA coverage.
• COBRA can last for up to 38 months for spouses and dependents facing a loss of employer-provided coverage due to an employee’s death, a divorce or legal separation, or certain other qualifying events.
• The original purpose of COBRA was to protect people from pre-existing condition clauses that could deny them health insurance.
• The Affordable Care Act (ACA) reformed the private health insurance market to make coverage more comprehensive than it used to be, and available to everyone, regardless of medical history. This has increased the options available for coverage outside of an employer group.

Glossary

• Affordable Care Act (ACA) — The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
• Claim — A request for payment that your health care provider (such as your doctor, clinic, or hospital) sends to the health insurer. This invoice shows exactly what services you received.
• Coinsurance — Cost-sharing in which the insured pays a share of the payment made against a claim. For example, your Health Plan pays 80% and you pay 20% for covered medical equipment.
• Copayment — A fixed charge that you must pay for a covered health care service, usually at the time you receive the service.
• Cost-sharing — The share of costs for covered services that you must pay out of your own pocket. This term usually includes deductibles, copayments, and co-insurance.
• Deductible — The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
• Flexible spending account (FSA) — An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses — such as copayments — with tax-free dollars. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don't have to pay taxes on this money. Generally, FSA funds do not “carry over” from one plan year to the next. This means that the funds left unspent at the end of the plan year cannot be used for expenses in the following year. However, your employer’s FSA plan may permit you to use unspent FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year.

Glossary

• Fraud & Abuse — A deception deliberately practiced in order to secure unfair or unlawful gain. Insurance fraud occurs when claims are submitted with services that were not rendered, or services that the patient was told would be free, and providing any other false information in which an insurance company would base claim payment on.
• Health Insurance Marketplace — A transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. The Marketplace offers you a choice of health plans that meet certain benefits and cost standards. In 2014, members of Congress began getting their health care insurance through the Marketplace as well as all uninsured Americans.
• Health savings account (HSA) — A special tax-advantaged savings account designated for qualified medical expenses. To be eligible to open and make contributions to the HSA, you must be covered by a qualified high-deductible health plan (HDHP). Employees own their HSA at all times and the account is portable. That means you can take the account with you when you change medical plans, change jobs, or retire. However, you have to be covered under a high deductible health plan (HDHP) in order to make contributions.
• High deductible health plan (HDHP) — A health insurance plan with a minimum deductible that must be met before the health plan begins to pay. The minimum deductible for a plan to be categorized as an HDHP varies each year as determined by the Internal Revenue Code (IRS). Being covered by a HDHP is also a requirement for having a health savings account.
• Medical Necessity — The evaluation of health care services to determine if they are medically appropriate and necessary to meet basic health needs; consistent with the diagnosis and rendered in a cost-effective manner; and consistent with national medical practice guidelines regarding type, frequency and duration of treatment
• Open enrollment period — The period of time when people can choose a new health plan. This usually occurs once a year.

Glossary

• Out-of-pocket maximum — The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100 percent of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn't cover. Some health insurance or plans don't count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums.
• PCP — A primary care physician; the PCP’s practice is devoted to internal medicine, family/general practice and pediatrics. An obstetrician/gynecologist is sometimes considered a primary care physician depending on the health plan. A PCP is responsible for all routine health care services for the patient.
• Premium — The specific amount charged to covered groups and individuals. An individual or their employer normally pays this monthly or yearly. Depending upon a number of different variables, actual premiums for covered individuals and groups may be higher or lower than a filed rate. (A premium is sometimes confused with a rate.)
• Prior Authorization — The process of obtaining prior approval for medical services based on a plan’s Evidence of Coverage, or the process of obtaining prior approval for prescription medications based on a plan’s drug formulary (list of covered drugs)
• Preventive service — A recommended routine health care service or screening that may be covered at no cost to you by your health plan.
• Procedure codes — Also called CPT codes — The health care industry’s standard for the reporting of physician procedures and services.
• Qualifying life event — A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage.
• Referral — The recommendation by a physician and/or health plan for a covered member to receive care from a different physician or facility.
• Specialist — A health care provider who is not a primary care physician. Examples: Cardiologist (specializes in disorders of the heart), Orthopedist (specializes in treatment of skeletal system, muscles, joints and ligaments)