Glossary of Health Plan Terms
Below is a list of common health care terms and phrases.Co-insurance
Co-insurance refers to the percentage of the covered expenses that you and the plan will pay. For example, an 80 percent co-insurance means the plan will pay 80 percent of the fees; you will pay the remaining 20 percent. PPO plans will typically pay a higher co-insurance amount for in-network versus out-of-network services. Co-insurance generally applies after you have met a deductible.
Co-insurance Limit
A co-insurance limit is also sometimes called an out-of-pocket maximum, and it is another protection built into PPO plans. A co-insurance limit is a set amount that limits the total amount of co-insurance you have to pay for the year. Once you reach the co-insurance limit, the plan pays 100 percent. Check your plan to find out what fees do not count toward the co-insurance limit; typically, co-pays, deductibles and penalties are excluded.
Co-payments (or Co-pays)
Co-pays are flat dollar amounts that are paid at the time of service. For example, you may have a $15 per office visit co-pay for doctor visits and a $25 per office visit co-pay for specialist visits. There may be separate co-pays for different services. Some plans may require that a deductible first be met before a co-pay will apply.
Deductibles
Deductibles in health care plans are similar to the deductibles on your car insurance. They are an amount that you must pay before the health plan will pay for any covered services. Some plans have separate deductibles for in-network services versus out-of-network services. There are individual deductibles and family deductibles. The individual deductible applies to each individual's use of services. All individual deductibles also apply to the family deductible limit. The family deductible limits the amount of individual deductibles a large family may have to pay. Each individual must pay his or her individual deductible until the combined individual deductibles paid reach the family deductible limit. In that case, all family members will be considered to have met their individual deductible. Deductibles must be met every calendar year and once met, the co-insurance applies. The deductible rules are not the same for all health care plans. In most cases, co-payments are not counted towards the deductible limit.
Dependent
Your legally married spouse/qualified domestic partner and/or your unmarried child(ren) under age 19, or full-time students less than 24 years old who are eligible for health care coverage under your medical plan.
Dual Coverage (Coordination of Benefits)
Some employees and dependents have health care coverage under another employer's plan in addition to the McClatchy plan. For instance, children might be covered under both the McClatchy plan and the spouse's medical plan. This is called dual coverage. When there is dual coverage, the health plans may coordinate benefit payments. Plans may pay dual coverage in a variety of ways so you should check your Summary of Coverage booklet to find out what rules affect you.
Emergency Care
"Emergency" means an unexpected illness or injury that may be life-threatening if immediate medical attention is not given. If you require emergency care, call "911." If your personal physician does not authorize your emergency room visit or if your condition is not considered an emergency, your coverage may not be covered by the plan.
Explanation of Benefits (EOB)
Explanation of Benefits is a form produced by the health plan every time there is a claim submitted. The EOB will show you the dollar amount of the claim submitted for payment and how much was paid by the plan. EOBs are typically used for PPO plans and may not be sent if you do not have any responsibility for any of the payment. EOBs also keep track of your deductibles.
Formulary
A formulary is a list of preferred approved drugs covered under the health care plan. Drugs not listed on the plan's formulary are considered brand non-formulary drugs and are either 1) not covered, or 2) if covered, are usually much more expensive.
In-Network Doctor
In-network doctors, also called Preferred Care Providers, have agreed to charge a discounted rate for services and most PPO plans will pay for a larger percentage of these charges. An in-network doctor is a doctor that specifically accepts your insurance carrier and plan type. For example, if you have the Aetna PPO plan, you will need to find a doctor that accepts Aetna PPO insurance in order to have the health care plan cover the maximum amount of charges allowed by the plan. If you have the HMO plan, the same rule applies. Networks are not the same; doctors in a PPO network are not necessarily also in the HMO network.
Negotiated Amount
Also called the discounted rate or allowed rate, this is the rate that the provider or facility in a PPO plan network has agreed to accept for services, and is the amount that the in-network co-insurance percentage is based upon.
Open Enrollment
The period of time designated each year as the time that eligible employees can make changes to their health care selections.
Out-of-Network Doctor
Out-of-network doctors, also called non-preferred care providers, do not have a negotiated contract with the health care plan. Out-of-network services tend to be much more expensive because these doctors charge more than the discounted rate and the percentage of the charge paid by the health plan is generally less. In addition, if the out-of-network doctor's bill is more than the discount rate, the patient can be billed for the amount in excess of the negotiated rate.
Out-of-Pocket Maximum
Out-of-Pocket Maximum, also called the co-insurance limit, is typically used with PPO plans. This is the maximum amount of co-insurance you have to pay in a year before the plan pays 100 percent co-insurance. This amount typically does not include money paid toward co-pays, deductibles or penalties.
Outpatient
An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning the patient does not stay overnight in a hospital or in-patient facility. Many plans have identified a list of tests and procedures (including surgery) that will not be covered unless they are performed on an outpatient basis. The term "outpatient" is also used synonymously with the word "ambulatory" to describe health care facilities where outpatient procedures are performed.
Precertification/Preauthorization/Medical Necessity
Some procedures or prescription drugs require precertification or preauthorization in order to be covered. The health plans do this in order to ensure the procedures or drugs are medically necessary and appropriate for the diagnosis. Even if your physician recommends a service, it may not be covered unless it is medically necessary. Services typically covered under precertification requirements include in-patient surgeries, hospital stays, hospice care, and skilled nursing facilities. You can check your Summary of Coverage booklet, the health plan customer service line, or human resources to determine which benefits require precertification, and whether you or your provider is responsible for obtaining the precertification from the health plan. Generally, you will be responsible for obtaining the required precertification if you are using services from an out-of-network provider. Some plans will charge a penalty if you do not obtain the required pre-certification.
Pre-existing Condition
An illness, injury or health problem that existed six months before the date your insurance became effective.
Preferred Provider Organization (PPO) Plan
PPO stands for Preferred Provider Organization. Participants in a PPO have two options -- to seek care in-network or to use a provider who is not in the network -- or "out-of-network." In-network doctors have agreed to charge a discounted rate for services and most PPO plans pay for a larger percentage of these charges. Out-of-network services tend to be much more expensive because these doctors charge more than the discounted rate, the percentage of the charge paid by the health plan is generally less, and the patient can be billed for the amount in excess of the negotiated rate.
Prescription Drugs
Prescription drug plans often categorize drug coverage as generic or brand, and formulary or non-formulary. The benefit amount paid will vary depending on the drug's category, with the highest level of benefit paid for generic formulary drugs.
* Generic Drugs are drugs that are no longer protected by trademark. They are sold under the common chemical formulation name.
* Brand-Name Drugs are drugs that are protected by trademark and are more expensive. They include drugs commonly advertised on television.
Preventive Care
Many (but not all) plans pay 100 percent for preventive care coverage. Child immunizations, routine physicals, well-women exams and routine mammograms, are all covered under preventive care. Preventive care services usually require a co-pay or are paid at 100 percent co-insurance and generally are not subject to the deductibles. You should ask your doctor to be sure to code these services as preventive care on the claim form sent to the health plan.
Primary Care Physician (PCP)
Some plans require you to have a Primary Care Physician (PCP), who is a doctor that will direct all of your care. You can have a different PCP for each member of your family. If your plan requires a PCP, you must obtain a referral from your PCP before you may see a specialist in order for your expenses to be covered by the plan.
Specialist
A physician who practices in a medical or surgical specialty that provides non-routine care.
Summary of Coverage (SOC)
Summary of Coverage booklets are sometimes called evidence of coverage booklets or summary plan description booklets. These booklets provide detailed descriptions of the benefits that are covered under the plan as well as other legal notices such as the plan's appeals process. They also may specify benefits that are excluded or not covered by the plan.
Urgent Care
Urgent means a sudden illness, injury or condition severe enough to require prompt medical attention, or that can become an emergency if not treated in a timely manner. Urgent care does not require the level of services of an emergency room or hospital.