Terms to Know

Claims Administrator

The insurance company or third party that reviews, approves, and pays benefits claims.

Coinsurance

Once you’ve met your annual deductible, coinsurance is the percentage of costs you’ll pay out of pocket for services covered by your plan (until you meet your out-of-pocket maximum for the year).

Copay

The fixed amount you pay for an in-network service.

Deductible

The amount you must pay for covered health services each year before the plan begins to pay its share of costs. The deductible may not apply to some services, including preventive care, in network doctor visits, and services billed by a YNHHS facility.

Each family member covered under the plan must meet the deductible each calendar year. The deductible does not include copays, amounts exceeding the maximum allowable amount (MAA), prescription drug expenses, or expenses not covered by the plan.

Example: The individual deductible for the High-Deductible Health Plan is $2,000. When two covered members of your family have each met their $2,000 deductible, the $4,000 family deductible for the year will have been met. After you meet the deductibles, the plan will pay its share of costs for all covered family members during that calendar year.

Dependent Children Over Age 26

You can continue coverage for your fully handicapped dependent child past the child’s 26th birthday only if you submit proof within 31 days of the child’s 26th birthday that the child is disabled. Coverage will end in the following situations: when your child is no longer handicapped, if you do not provide proof of continued disability, if you fail to have any required exam for that child, or when dependent coverage terminates for any other reason.

Diagnostic Care

Specific care and/or procedures that help a doctor investigate symptoms or test results and make a diagnosis.

Example: You typically receive preventive care during an annual checkup. If a preventive screening yields an abnormal result, you may receive diagnostic care to determine why.

Health Reimbursement Account (HRA)

An account offered in conjunction with the HDHP for employees enrolled in Medicare or TRICARE. Your employer contributes to your HRA. As you receive services throughout the year, you pay out of pocket for expenses like coinsurance, copays, and other services, and then get reimbursed from your HRA up to the amount of your existing balance. Unlike an HSA, the HRA is not portable; you can’t take it with you if you leave your employer or change medical plans.

Health Savings Account (HSA)

A special account that’s typically paired with a high-deductible health plan (HDHP). You and/or your employer contribute to the account, and you can use these funds to cover qualified healthcare expenses, including your annual deductible, copays, and coinsurance. Annual contributions for individuals and families are set by the IRS; for 2021, you can contribute up to $3,600 if you have individual coverage, and up to $7,200 if you cover others, too. The money in your HSA is yours to use into retirement, even if you change plans or employers.

High-Deductible Health Plan (HDHP)

A health plan with a higher annual deductible than most PPO plans, but it doesn’t begin to share the costs for covered services until you meet the $4,000 annual deductible. To help you cover these costs, you can use funds in the Health Savings Account (HSA) or Health Reimbursement Account (HRA) that’s paired with your HDHP.

In-Network Provider

The facilities, providers, and suppliers that Anthem Blue Cross and Blue Shield has contracted with to provide health care services.

Maximum Allowable Amount (MAA)

The maximum amount that Anthem will pay for a covered service or the billed charge—whichever is lower. Applies to out-of-network services only.

Out-of-Network Provider

Any provider or facility that has not contracted with Anthem Blue Cross and Blue Shield and is not part of Anthem’s Century Preferred Network. Anthem will pay up to the MAA for these services, and all claims will be subject to applicable deductibles and coinsurance.

Out-of-Pocket Costs

Any cost or fee that you pay for medical services, prescription drugs, or medical supplies. These include your annual deductible, and copays and coinsurance.

Out-of-Pocket Maximum

The most you will pay in a calendar year for medical or prescription drug expenses. Once the out-of-pocket maximum has been met, the play pays 100% of covered expenses for the covered person or family for the remainder of the calendar year, including copays and expenses that are applied toward the annual deductible.

The out-of-pocket maximum does not include benefit reductions due to failure to precertify, covered expenses paid at 100%, expenses exceeding the MAA, expenses not covered by the plan, or employee premium contributions.

Preferred Provider Organization (PPO)

Doctors, hospitals, and other providers who have agreed to negotiated fees with Anthem. Typically, you’ll pay less than you would for services from a non-PPO provider.

Preventive Care

Screenings, annual checkups, and patient counseling to prevent illness, disease, or other health problems. Under the Affordable Care Act (ACA), all health plans must cover certain preventive health services at no cost to the patient. Some prescription drugs are also considered preventive under the ACA and are covered at 100%.

Primary Care Physician

A medical doctor who provides or coordinates health services for a patient. Primary care physicians are typically aligned with internal medicine, general or family medicine, and pediatrics practices.

Prior Authorization

A decision reached by your health plan—before services are performed or purchases are made—that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Your plan may require prior authorization for certain services, except in an emergency. Prior authorization is not a promise that your plan will cover the cost. Prior authorization for prescription drugs ensures medications are safe and being prescribed for FDA-approved uses.

Qualifying Life Event

A major life event—including a change in family size, marriage, divorce, or loss of current coverage—that allows you and/or eligible family members to enroll in or make changes to your existing health coverage. If you experience a qualifying life event, you must make the change within 31 days on our enrollment site.

Specialist

A physician who focuses on a specific area of medicine to diagnose, manage, prevent, or treat certain symptoms and conditions.

Examples include allergist, cardiologist, dermatologist, orthopedist, podiatrist, ear/nose/throat, gastroenterologist, OB/GYN, ophthalmologist.

Voluntary Benefits

Products offered through an employer that the employer typically pays for at below-market rates. These can include life, disability, critical-illness, accident, homeowner’s, auto, and pet insurance; ID theft protection; legal services; and other benefits.