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 calendar year).

Compounded Drugs

Customized medications developed for an individual based on a doctor’s prescription. Prescriptions for compounded medications will require prior authorization from CVS Caremark. They will be covered as Tier 3 medications. You can get 30-day fills at a CVS retail pharmacy; larger fills are available through the CVS Caremark Maintenance Choice program.

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 YNHHS Medical Plan is $3,500. When two covered members of your family have each met their $3,500 deductible, the $7,000 family deductible for the year will have been met. From then on, the plan will pay its share of costs for them and any other covered family member 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.

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.

In-Network Provider

The facilities, providers, and suppliers that Anthem Blue Cross and Blue Shield has contracted with to provide health care services. The YNHHS plans have two types of in-network providers:

The Signature network includes: YNHHS facilities/hospitals, PCP’s from NEMG, Community Medical Group (CMG), Yale Medicine (YM), WestMed in CT, Trinity Health of New England hospitals and affiliated physicians. Also included are specialists from YM, NEMG, CMG and Trinity Health, and those credentialed at YNHHS.
Anthem Preferred Provider Organization (PPO) includes providers and facilities in Anthem’s Century Preferred network.

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 maximum allowed amount (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 receive prior authorization, covered expenses paid at 100%, expenses exceeding the maximum allowed amount (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, and 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 item 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 marriage, divorce, a change in family size, or the 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.