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Glossary of Benefit Plan Terms

Your Guide to Understanding Health Plan Terminology

Understanding health care and benefit plan terms can be confusing — especially with all of the acronyms and insurance-industry terms used. Let us help you make sense of it all and provide some clarity.

Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate”. If your provider charges more than the allowed amount, you may have to pay the difference.

A request for a review of a denied claim. Appeal request timeframes and the levels of appeal vary by plan and will be outlined in your plan's SPD or Summary Plan Description. (See Summary Plan Description)

Tune in to Nova's Under the Coverage podcast to hear about things to think about when you have questions about a letter you received.

An Administrative Services Organization (ASO) refers to the administrative support services necessary to operationalize a self-funded benefit plan. ASO most often refers to administrative services provided through a traditional, brand name health insurance carrier.

A request for direct payment or reimbursement for medical services that an insured person has obtained. Claims are most often submitted by providers directly to the insurance company or benefit plan administrator. Once a claim is processed, the patient will receive an Explanation of Benefits (EOB).

You go to the doctor. The doctor submits a claim for payment. That process is called claims adjudication. In five minutes you can learn about the behind-the-scenes process to understand how claims are processed by listening to our podcast episode on the life of a claim

Case Management is care coordination assistance, education and support for members, their families and/or caregivers. Registered nurse case managers provide support for members facing challenging health issues or who are considered high-risk for health issues. (i.e., those with complex/catastrophic care needs)

A case manager from your health plan may call to provide assistance with your care needs. A case manager can help you understand your plan of care, identify resources to support you in managing a medical condition, coordinate with providers and make sure you are getting the most out of your benefits.

Learn more about how a case manager can help you or a dependent on your plan. You can also tune in to our podcast episode titled "Your Health Plan is Calling" to learn more about the ways we aim to support members in their health journey.

CMS formally refers to the Centers for Medicare and Medicaid Services which is a federal agency that administers the Medicare program and monitors the Medicaid programs offered by each state.

The percentage of costs of a covered health care service a member pays after the deductible is met. We can help you untangle the difference between copay, conisurance, deductible and out-of-pocket maximum. Tune in for more details.

Private insurance commonly obtained through an employer but also available on the ACA marketplace. Insurers provide a selection of defined plans and the employer (or member through the ACA marketplace) pays a flat fee for access to the selected plan.

Coordination of Benefits refers to the process by which medical benefits are adjusted or coordinated to accommodate instances where another insurance policy may also play a role in covering medical claims. If a member is covered by more than one medical insurance plan or if another insurance might be responsible for paying your claims, the COB department reviews claims to determine which insurance is primarily responsible for payment.

Members will receive communication from their benefit plan requesting additional information about a claim when they believe another insurer may be responsible for payment. For example, if you receive treatment for a back injury, it is possible that it's related to a car accident, workers compensation or another incident involving a third party. In those cases, an insurer other than your employer-sponsored medical insurance may be the primary payer. It's also possible your back injury is simply the result of a big sneeze! So, if you receive a request for additional details, it is important to complete that information to assist in proper payment of your claims.

Want to learn more? Check out this episode of Nova's Under the Coverage podcast to hear one of our claims adjudicators talk about the coordination of benefits process. 

Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that requires employers to offer continued health insurance coverage to employees whose group health insurance coverage has terminated. COBRA coverage is an extension of your current plan. Administration of COBRA benefits is generally handled by a third party.

A copay or copayment is a fixed out-of-pocket amount paid by a member for covered services after deductible is met. This amount varies by plan and by service received.

We can help you untangle the difference between copay, conisurance, deductible and out-of-pocket maximum. Tune in for more details.

Current Procedural Terminology (CPT) codes are descriptive terms and identifying codes for medical services and procedures performed by providers. CPT codes are used by the billing provider and submitted as a claim to your medical insurance. Your insurance company reviews the claim and CPT coding compared to your benefits to determine plan payment amount and member responsibility. After any type of medical service or procedure, a member will receive an explanation of benefits (EOB). The EOB will provide an overview of how the claim was processed.

Want to learn more? Listen to this 10-minute podcast episode about all that an EOB can tell you!

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 will not pay for services 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.

We can help you untangle the difference between copay, conisurance, deductible and out-of-pocket maximum. Tune in for more details.

Direct Primary Care (DPC) is a membership-based model of care where patients pay a monthly fee to access care as needed. This is different than a traditional fee-for-service model available through traditional insurance plans.

DPC is a newer model of care and as a newer option, we talked with Nathan who understands what direct primary care is. Tune in to A PCP with DPC to learn more.

Disease Management (chronic condition management) – Disease Management programs are designed to improve quality of life and reduce health care costs for members. Registered nurses outreach to members to help them better manage chronic conditions using evidence-based clinical guidelines and education. Nurses also leverage the member's benefit plan to help the member understand the most cost-effective way to manage their condition.

Durable Medical Equipment is used to serve a medical purpose; is not useful to a person in the absence of illness or injury; and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a health care provider for everyday or extended use. DME may include items such as oxygen equipment, wheelchairs, hospital beds, or crutches.

We've learned some questions to ask about DME to help you navigate the conversation around the cost of equipment with the provider's office. Tune in for 10 minutes to hear some quick tips.

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. Emergency hospital services that are necessary to prevent death or serious impairment of health, and because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. An emergency medical condition is an illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Medical services that your health plan doesn’t pay for or cover. Understanding what your benefit plan covers is important but you don't want to find out something isn't covered when it's too late. Learn more about the questions you can ask to confirm coverage before you get the bill.

Explanation of Benefits is the statement sent to covered persons by their health plan listing services provided, amount billed, and payment made. An EOB is not a bill. If a patient owes any amount to the provider, the provider will bill the patient separately.

Want to learn more? Listen to this 10-minute podcast episode about all that an EOB can tell you!

A flexible spending account or FSA is a savings account that allows employees to contribute a portion of their regular earnings, pre-tax, to pay for qualified expenses. FSA funds are not subject to income and payroll taxes. FSAs come in a variety of forms to offset costs for a variety of expenses including dependent care accounts (DCA), parking and transit or "qualified transportation" (QTA), medical FSAs or limited purpose FSAs. It is important to understand your plan's grace period, rollover and runout guidelines to ensure you are maximizing your reimbursements.

We can help you understand how reimbursement plans work and how you can figure our what's eligible. Tune in to our FSA, HRA & HSA Oh my! episode.

A benefit plan that requires the enrollee to pay for most medical expenses, up to a certain dollar amount, before the insurance policy begins to cover them. High Deductible Health Plans (HDHP) are often paired with an HSA where employees can set aside pre-tax funds to cover out-of-pocket expenses.

An HDHP with an HSA can be a good opportunity for savings but the up-front out-of-pocket costs can be intimidating. If you're in an HDHP or if you're considering enrollment in one, we can help

HIPAA refers to the Health Insurance Portability and Accountability Act of 1996. HIPAA a federal law that requires the protection of health information which includes obtaining a patient's permission to disclose information. 

HIPAA forms are available in a writable-PDF format along with instructions to return a completed authorization on Nova's resources page.

A Health Maintenance Organization (HMO) is an insurance plan that contracts with providers and facilities to provide care at a reduced rate.

An HRA is a pre-tax account used to pay for eligible medical expenses. Typically, HRAs are designed to complement or supplement your health plan. Your employer or group determines what medical expenses are eligible. An HRA is funded by your employer.

We can help you understand how reimbursement plans work and how you can figure our what's eligible. Tune in to our FSA, HRA & HSA Oh my! episode.

An HSA is an account for individuals covered by a qualified high-deductible health plan. The account can be funded by you, your employer or both. A bank will administer your HSA directly and provide you with the materials to manage your account most effectively. The bank also serves as “trustee” or “custodian” of your accounts.

Funds in the HSA can be used to pay for qualified medical expenses. Any unused dollars grow tax-free, carry over year-to-year, and move with you from job to job. Unused dollars earn interest or can be invested, similar to a 401k plan, in the investment funds available through the bank that manages your HSA.

It can be hard to imagine having "extra" money to invest in an HSA. Tune in to hear from an employee who learned how to maximize her HSA.

Refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. To view participating providers visit our Find A Provider page.

Your member ID card holds the key to help you understand how you can identify in-network providers. We can walk you through all the things your ID card can tell you about your benefit plan. Tune in now.

This status applies when a patient is admitted to a hospital or clinic for treatment that requires at least one overnight stay. You will need to cover the cost for the plan’s applicable deductible, any applicable copayment or coinsurance, and/or any additional payments if you go to a facility that is not in-network.

Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

The facilities, providers and suppliers your health plan has contracted with to provide health care services at a discounted rate. Your network logo will appear on your medical ID card. Visit our Find a Provider page to find an in-network provider. Some plans utilize direct primary care (DPC) or reference based pricing (RBP) in lieu of a traditional network. In these instances, you will not find a traditional network logo on your medical ID card.

A provider who has not contracted with your health plan to provide services to you at a discounted rate. A non-participating provider is also referred to as an  "out-of network" provider. You will pay more to see a non-participating provider. 

We have some tips to help ensure you're using an in-network provider for services. Our podcast has two episodes dedicated to this topic. Tracey and Alicia address the steps that can help you save money.

If you visit a non-participating physician or hospital, your service is subject to your deductible, plus any copayment and/or coinsurance and balance billing. In less than 10 minutes, you can learn some questions to ask to help you protect your wallet.

The out-of-pocket maximum is the dollar limit for deductibles, copayments and coinsurance amounts that you are responsible for in a given time period. Payments to a non-participating provider does not count toward the out-of-pocket maximum.

The term "par" or "par provider" is the same as "participating provider." A participating provider is one that is contracted with your benefit plan to provide services to you and your dependents at a discounted or negotiated rate.

A participating provider is one that is contracted with your benefit plan to provide services to you and your dependents at a discounted or negotiated rate.

A consecutive 12-month period during which a health plan provides coverage for health benefits. The 12-month period may not be the same as a calendar year. Plan effective dates are determined by your plan, for example, a plan with a July 1 effective date provides coverage through June 30 of the next year.  

A preferred provider organization or PPO plan does not require members to select a primary care physician and does not require referrals to see specialists.

Prior authorization and precertification both indicate a responsibility for obtaining authorization for a service prior to service delivery. Prior authorization indicates that authorization is the responsibility of the provider. Services requiring prior authorization vary by network and can vary by employer. Precertification indicates that the member is responsible for contacting the plan administrator to obtain authorization for a service prior to receiving services. As a member, it is important to understand which services require precertification to ensure coverage in accordance with the plan.

Want to learn more? Listen in to our podcast episode, These Boots Are Made For Walking... and They May Have Required Precertification!

The amount that must be paid for your health plan coverage. 

Drugs and medications that by law require a prescription. Most often, a pharmacy benefit management company may administer your pharmacy benefits. Some pharmacy benefits are processed under your medical plan and others will bill through your pharmacy plan. It can be confusing, but in this podcast episode with Carly, we help you understand some of the complexity.

Preventive care services* focus on the prevention, early detection and early treatment of conditions, generally including routine physical exams, immunizations, well-visits and screenings to prevent illness, disease and other health-related problems. Preventive care services may be covered in full when rendered by a participating provider however, other services may be performed in conjunction with the preventive care services. You may be responsible for any additional copayment or coinsurance for those services.

*Does not include procedures, injections, diagnostic services, laboratory and X-ray services, and any other service not billed as an Evaluations and Management code (E&M code) as preventive.

A PCP is a physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient including periodic examinations, immunizations, diagnosis and treatment of illness and injury; coordinates the patient's overall medical care and record maintenance.

Learn more about the importance of identifying a PCP to be the quarterback of your care. Nova's Under the Coverage podcast discusses the value of preventive care and we also talk to a PCP about the importance of owning your medical records. 

The primary payer is the insurance policy that pays first when a person is covered by more than one insurance plan.

Provider is a term general term often used for health professionals who provide health care services. Sometimes, the term refers only to physicians however, it can also include other health care professionals such as registered nurses, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services. A licensed, certified or accredited health care facility such as a hospital can also be considered a provider.

Reference Based Pricing is also referred to as Medicare Reference-Based Pricing. In an RBP arrangement, the plan pays a set price in excess of Medicare rates for each health care service instead of using set negotiated rates with providers by using network discounts. For example, if the Medicare rate for a service is $1,000 and the plan pays 150% of Medicare rates, the plan will pay $1,500 for that service. If a provider charges $2,000 for this service the provider may balance bill a member for the amount in excess of the plan payment. However, many plans contract with vendors to support members to minimize balance billing.

A secondary payer refers to the insurance that pays after the primary payer's payment responsibility has been identified.

Self-funded insurance is different than fully insured benefit plans. In a self-funded arrangement the employer assumes the financial risk for providing health care benefits to its employees. In practical terms, self-insured employers pay for claims out of pocket as they are incurred instead of paying a fixed premium to an insurance carrier, regardless of claims incurred, for a fully-insured plan.

A Summary Plan Description or SPD is a written statement of a plan in an easy-to-read format that includes a statement of elegibility, coverage, employee rights and appeal procedures.

Understanding your benefits is one of the keys to managing cost. Listen in to hear more about what you should look for and the questions you can ask to help you save money and get the most out of the benefits you have.

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

The day an insurance policy ends. A scheduled termination or policy end date occurs on the last day of an annual plan. For example, a plan with a January 1 effective date will have a termination date of December 31. An unscheduled termination occurs when an employee is no longer eligible, such as an employee who terminates or is terminated from employment. This can occur on any date in the plan year.

A Third Party Administrator (TPA) is an organization hired by an employer to provide administrative services for benefit plans. TPAs adjudicate claims, provide customer service, and possibly medical management, compliance support, plan design guidance and cost containment services.

Utilization review (UR) is the process of evaluating medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities according to evidence-based criteria or guidelines. (See Prior Authorization and Precertification)

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Urgent care is generally more affordable than emergency room care and has shorter wait times.

Nova’s Under the Coverage Podcast 

Nova’s Under the Coverage podcast talks to people who work in the health benefits industry. They share tips on how they leverage what they know to better navigate the health care and health benefits systems. Each of our guests, at some point, was new to the benefits industry as an employee so we appreciate all we've learned along the way. We hope we can help you too!

Check it out on your favorite podcast platform.