Glossary of Healthcare Terms

BRAND-NAME DRUG:

Drugs developed and produced exclusively by a single pharmaceutical company. The formula for these drugs is protected by patent for a period of several years before a generic can be developed.

BROKER:

A broker matches their clients with a health insurance company or plan that best suits the client’s needs. The broker is paid a commission by the insurance company but represents the interests of their client rather than the insurance company. In some cases, as with Gallagher Benefit Services, a broker can also act as a third-party administrator, handling enrollment and billing, benefit and claims questions, etc.

CLAIM:

A request by a plan member, or a plan member's health care provider, for the insurance company to pay for medical services.

COINSURANCE:

The amount that you are required to pay for covered medical services after you've satisfied any copayment or deductible required by your health insurance plan. Coinsurance is typically a percentage of the charge for a service rendered by a healthcare provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance.

COPAYMENT:

A flat charge that your health insurance plan may require you to pay for a specific medical service or supply, also referred to as a "copay." For example, your health insurance plan may require a $20 copayment for an office visit or brand-name prescription drug, after which the insurance company pays the remainder of the charges.

COBRA (Consolidated Omnibus Reconciliation Act):

Federal legislation allowing an employee or an employee's dependents to maintain group health insurance coverage through an employer's health insurance plan, at the individual's expense, for up to 18 months after the loss of employment.

DEDUCTIBLE:

A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible.

DEPENDENT:

A person who is depending on you for financial support and therefore eligible to enroll in a group sponsored benefit plan that you are eligible for. Dependents are usually: spouse, domestic partners, and children.

EXPLANATION OF BENEFITS (EOB):

The statement sent to you by your health plan explaining the benefit calculation and payment of medical services that details the services rendered and the benefits paid or denied for each service. An EOB lists the charges submitted, the amount allowed, the amount paid, and any balance owed as the patient's responsibility.

FORMULARY DRUG:

List of prescription drugs approved for a health plan's prescription drug benefit. Formulary lists are available at Anthem's website or you can call Anthem's Customer Service number and request a copy.

GENERIC DRUG:

A prescription drug that is chemically equivalent to a brand name drug dispensed under its generic chemical name. Generic drugs are cheaper versions of expensive brand name drugs with the same active ingredients, strength and dosage form.

INSURANCE CARRIER:

The company responsible for providing you with your health insurance plan by paying your claims, maintaining provider networks, coordinating billing, and offering member assistance services.

IN-NETWORK PROVIDER:

A healthcare professional, hospital or pharmacy that has a contractual relationship with your health insurance company. This contractual relationship typically establishes allowable charges for specific services. In return for entering into this kind of relationship with an insurance company, a healthcare provider typically gains patients, and a primary care physician may receive a capitation fee for each patient assigned to his or her care. An Out-of-Network provider is a healthcare professional, hospital, or pharmacy that is not part of your health plan's network of preferred (In-Network) providers. You will generally pay more for services received from out-of-network providers, in part because you may be responsible for out of-pocket costs that are considered above the “reasonable and customary” fees.

LIFETIME MAXIMUM:

The maximum dollar amount that a health insurance company agrees to pay on behalf of a member for covered services during the course of his or her lifetime.

MEDICAL EVACUATION AND REPATRIATION INSURANCE:

This coverage, required of all J-Visa holders, is for arranging and paying for emergency evacuation to the nearest adequate medical facility, and the repatriation of mortal remains.

NON-FORMULARY DRUG:

Any brand-name prescription drug that is not included in a particular health plan's list of approved formulary drugs.

OPEN ENROLLMENT:

The time period each year when you have an opportunity to change your benefit elections. Examples of changes: switch from one medical plan to another; add dependent(s) to medical/dental if not enrolled in your plan.

OUT-OF-NETWORK PROVIDER:

A doctor, dentist, hospital or other practitioner who does not have a contract with a health plan.

OUT-OF-POCKET MAXIMUM:

Out-of-pocket maximums apply to all medical plans. This is the maximum amount you will pay for health care costs in a calendar year. Once you have reached the out-of-pocket maximum, the plan will fully cover most eligible medical expenses for the rest of the plan year.

PATIENT PROTECTION AND AFFORDABLE CARE ACT (ACA):

ACA was signed into law on March 23, 2010. The ACA impacts only U.S. Citizens and Resident Aliens (“Green Card Holders”). This new law requires that all U.S. Citizens and Resident Aliens obtain health insurance coverage. In addition, the new law required changes to the level of coverage offered by each insurance carrier. Some of the changes include: coverage for pre-existing conditions and free preventive care.

PHYSICIAN:

Generally, a doctor that is categorized as a general practitioner, family practitioner, pediatrician, internist or OB/GYN.

PREFERRED PROVIDER ORGANIZATION (PPO):

A PPO is a network of doctors and hospitals that contracted with a health plan and have agreed to provide their medical services at rates lower than their standard fees. A PPO offers both in-network and out-of-network benefits.

PRIMARY CARE PHYSICIAN (PCP):

A primary care physician usually serves as a patient's main healthcare provider, especially under an HMO plan. The PCP serves as a first point of contact for healthcare and may refer a patient to specialists for additional services.

SPECIALIST:

Generally, a doctor that is NOT categorized as a general practitioner, family practitioner, pediatrician, internist or OB/GYN. Examples of a specialist would include a dermatologist or cardiologist.