Terms to Know
The following terms related to the YNHHS medical plans should assist you in understanding how the plans work.
Claims Administrator – Anthem Blue Cross & Blue Shield is our claims administrator. They are responsible for processing all claims, interpreting plan provisions and providing the “Century Preferred” PPO network. To find a provider in the Anthem PPO network, check on claims or request an ID card, visit Anthem or call 1-888-266-2896.
Coinsurance – Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, in the Advantage Plus Plan, certain expenses are covered at 80% by the Plan – you are responsible for the remaining 20%. Coinsurance in this case is 80%/20%.
Copay – A fixed amount (for example, $30) you pay when you see an in-network provider, usually at the time you receive the service. The amount can vary by the type of covered health care service you receive.
Deductible – The annual deductible is the amount you must pay for covered health care services (those “subject to deductible”) before the plan begins to pay. The deductible may not apply to all services. The deductible must be met by each covered member each calendar year (to a maximum of three per family). For example, the individual deductible in the Advantage Plan is $800. When three covered members of your family have each reached their $800 deductible, the $2,400 family deductible is met and no other covered family member will have to meet a deductible. For a family of two (you and one other covered member), each of you would have to reach their individual $800 to meet their deductible.
The deductible consists of your payments for expenses covered by the plan. It doesn’t include:
- Any copays you make for care through in-network providers
- Amounts exceeding the Maximum Allowable Amount (MAA)
- Any payments you make for expenses covered under the prescription drug plan (See Prescription Drug Coverage)
- Expenses not covered by the plan
The deductible may also apply to services received in a physician’s office (in addition to the of office visit copay). For example, you go to a dermatologist for a screening (you have a $40 copay in the Advantage Plus Plan). If, during that visit, the physician removes a mole, that is considered an out-patient procedure and the deductible and coinsurance could apply for that service.
Maximum Allowable Amount (MAA) – The Maximum Allowable Amount (MAA) applies to out-of-network services only. It is the maximum amount that Anthem will pay for a covered service, or the billed charges, whichever is lower.
In-Network Provider – The facilities, providers and suppliers your health plan (Anthem Blue Cross & Blue Shield) has contracted with to provide health care services.
The YNHHS plans have two types of in-network providers:
- YNHHS Facility/Provider: services provided and billed by Yale-New Haven Hospital, Bridgeport Hospital, Greenwich Hospital, Grimes Center, Lawrence + Memorial and Westerly Hospitals, Northeast Medical Group (NEMG) and affiliates. NEW! For Primary Care, we now have a Preferred Primary Care Provider network. The list of these providers is available on HRConnect.
- Anthem Preferred Provider Organization (PPO): Providers and facilities in Anthem’s “Century Preferred” network.
Out-of-Network Provider – Any provider/facility that has not contracted with Anthem Blue Cross & Blue Shield and, therefore, is not part of their “Century Preferred” PPO network. Anthem will pay up to a “Maximum Allowable Amount (MAA)” for these services, and all claims will be subjected to applicable deductibles and coinsurance.
Out-of-Pocket Costs – An out-of-pocket expense is any cost or fee for medical services that you pay. These include:
- Annual Deductible
- Copays or coinsurance
- Out-of-Pocket maximum
Out-Of-Pocket Maximum – The out-of-pocket maximum is the most you will ever pay in a calendar year to cover medical expenses. Once the out-of-pocket maximum is met, the plan pays 100% of covered expenses for the covered person or family for the remainder of the calendar year. This includes copays and expenses that are applied toward the annual deductible.
The out-of-pocket maximum does not include:
- Any benefit reduction required under our plans (see Precertification)
- Any covered expense for which benefits are initially paid at 100%
- Expenses exceeding the Maximum Allowable Amount (MAA)
- Expenses that are not covered by the plan
- Your employee contributions
Please note that there is a separate out-of-pocket maximum for prescription drug expenses (See Prescription Drug Coverage).
Preventive Care – Under the Affordable Care Act (ACA), all health plans must cover certain preventive health services. This includes screenings, annual checkups, and patient counseling to prevent illnesses, disease or other health problems.
Primary Care Physician – A physician (M.D. – Medical Doctor) who directly provides or coordinates a range of health care services for a patient. This includes Internal Medicine, General or Family Practice and Pediatrics.
Prior Authorization – A decision by your health care plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Your health care plan may require prior authorization for certain services before you receive them, except in an emergency. Prior authorization isn’t a promise your health care plan will cover the cost. For prescription medications, it will help ensure that employees and their dependents receive medications that are safe and are used in accordance with established guidelines, such as for FDA-approved indications, supported uses and routes of administration.
Qualifying Life Event – A change in your life that can make you eligible to enroll or make changes to your health coverage. Examples of qualifying life events are changes in your family size (for example, if you marry, divorce, or have a baby), changes to your dependent’s coverage, or losing your current coverage. If you experience a qualifying life event, you must process the change within 31 days in our Benefits portal.
Specialist – 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. Examples include: Allergist, Cardiologist, Dermatologist, Orthopedist, Podiatrist, Ear/Nose/Throat, Gastroenterologist, OB/GYN (except for annual preventive exam), Optometrist, Opthalmologist.
