Glossary of Terms

Appeal: When you ask your insurance company to review the decision not to pay for adrug or medical service.

Caps on Benefits: The limit on the total dollar amount insurance will pay. The cap may befor a year or a lifetime.

Case Manager: Often, registered nurses are hired by the insurance company or a hospital to decide the best treatment options available. They can help patients get their treat-ments. You may need to give them more information about your condition.

COBRA:Consolidated Omnibus Budget Reconciliation Act is a federal law that extends group health insurance for a certain period of time during a life event, such as leaving a job, getting a divorce, or a child turning 18 years old. You pay the full monthly premiums. Employers with 20 or more employees must offer extended health insur-ance through COBRA. More info on COBRA: Quote | COBRA | COBRA Alternatives | Healthy Access Database

Co-pay: A cost-sharing arrangement when you pay a specific charge for a specific service, such as $10 for a doctors visit. You are usually responsible for payment at the time of care or when getting a prescription filled. Typical co-pays are set amounts for doctor visits, prescriptions or hospital services. Sometimes they are a percentage of the costof the drug or service.

Creditable Coverage: Under HIPAA, this will reduce the amount of time your group health insurance can limit coverage based on a pre-existing condition. You get credit for each month you had coverage under another health insurance plan if you have not had more than 63 days without health insurance.

Deductible: Annual amount you have to pay before insurance pays your health care costs. This often applies to the total amount your family pays.

Denial of Coverage: When insurance will notpay a medical bill, they “deny you coverage.”Adenial of coverage can be appealed. Call your insurance company to find out how you can appeal.

Drug formulary: Alist of drugs that health insurance plan prefers a doctor to use. In somecases, the doctor can only prescribe drugs from this list unless an exception is obtained.

Exception Process: Process by which the doctor gets a letter from your insurnce company stating that specific drugs or services will be covered. A release is usually needed to get coverage for a non-formulary drug. It may require your doctor to call or write the insurance company asking for the release and explaining why it should be given.

Exclusion: Aservice or product that is notpaid for by insurance. Typical exclusions arecosmetic surgery, drugs to help quit smoking, or over-the-counter drugs.

Group Health Insurance: Insurance sponsored by your employer or by a large group ororganization.

Health Insurance Plan: An insurance company, Health Maintenance Organization (HMO)or other company that pays for health care, such as doctors visits, and drugs, for people in the plan.

HIPAA: Health Insurance Portability and Accountability Act is a federal law. If you haveapre-existing condition, it helps you to keep insurance when changing group health insurance plans.

Home Healthcare: Agency or organization that visits a patient’s home to provide services, such as IV therapy.

Plan network: Alist of providers that have anagreement with a health insurance plan toprovide services to patients covered by that insurance. Networks can include doctors, pharmacies and hospitals.

Pre-existing Condition: Any medical conditionthat has been diagnosed or treated within adefined period of time before you start your new health insurance. A waiting period maybe required. Some insurance may not pay for treatment of a pre-existing condition. Withgroup insurance, the waiting period can be up to 12 months. Creditable coverage canshorten, or get rid of, the waiting period.

Premium: The amount of money you mustpay, usually monthly, to your employer or insurance company to have health insurance coverage.

Prescription Drug Coverage: Defines the typeof coverage for prescription drugs. For example, it will specify the co-pay, limits on coverage and the type of formulary used.

Primary Care Physician: Usually your first contact for health care. This is often a family physician or internist, but some women use their gynecologist. A primary care doctor monitors your health and diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed.

Prior Authorization: You have to get the health insurance company’s approval before they will pay for certain services or drugs.

Provider: Someone who gives health care service to a patient. A “provider” can be a doctor, nurse, pharmacist or dietitian.

Yearly Re-enrollment: The requirement to choose a health insurance plan and sign upfor coverage every year. Depending on your employer, you may have the option to select from more than one health insurance plan.