A member’s request for their health insurer or plan to review a decision or a grievance again.
Behavioral Health Treatment
Means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism.
This is the 12-month period during which the Member’s or employer Group’s plan of coverage is effective for purposes of annual benefit accruals and limits, which may be either a calendar year (start date of January 1) or a plan year (start date varies based on employer Group’s contract).
Benefits and Coverage Matrix (BCM)
This is the disclosure form that provides details regarding copayments, coinsurance, deductible and out-of-pocket maximum amounts that apply to many covered services. The BCM also includes information related to other features of the benefits offered by Sutter Health Plus.
A request for payment that a member or their health care provider submits to the health plan.
A percent of the cost of a covered service members must pay. If a plan includes coinsurance, members will see the percent listed in their Summary of Benefits.
A specific dollar amount members pay each time they see a participating provider or receive certain covered services. Copayments may vary depending on the covered service. For example, doctor visits, emergency room visits and hospital stays have different copayments.
The amount members must pay for covered services (i.e., deductibles, copayments or coinsurance).
Covered California, HBEX, Health Benefit Exchange, Health Exchange
The public health insurance marketplace that helps people find health care coverage. In California, this marketplace is Covered California.
Coverage members had under any one or combination of the following as defined by federal law and applicable regulations:
- Health insurance coverage through a group medical plan or individual health policy
- Any other publicly sponsored program, provided in this state or elsewhere, of medical, hospital, and surgical care
- A medical care program of the Uniformed Services
- A medical care program of the Indian Health Services or of a tribal organization
- A State health benefits risk pool
- A State Children’s Health Insurance Program
- A health plan offered under the Federal Employee Health Benefits Program
- A public health plan, including any plan established or maintained by a State, the US Government, a foreign country or any political subdivision of the same
- A health benefit plan under section 5(e) of the Peace Corps Act
- Any other Creditable Coverage as defined by subsection (c) of Section 2704 of Title XXVII of the Federal Public Health Service Act
The amount members must pay each year for certain covered services before insurance will pay. Once the family deductible is satisfied by any combination of individual member payments, family members continue to pay copayments or coinsurance until the family out-of-pocket maximum (OOPM) is reached.
A subscriber’s spouse, domestic partner or child who is eligible for enrollment in a health plan.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Emergency Medical Condition
An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
The portion of the monthly health insurance premium paid for by an employee, usually deducted from wages by the employer.
The portion of an employee’s monthly health insurance premium paid for by the employer.
The process through which an approved applicant and his or her dependents or employees are signed up for health insurance coverage.
Evidence of Coverage and Disclosure Form (EOC)
This is the document that describes how, when and where a subscriber or enrollee can access covered health care services. In addition, it describes the limitations and exclusions provided for under the plan, how a subscriber or enrollee can file a complaint or grievance with the plan as well as other important features about the plan.
Specific conditions, services or treatments for which a health insurance plan will not provide coverage.
Explanation of Benefits
A statement sent from the health insurance company to a member listing services that were billed by a health care provider, how those charges were processed and the total amount of patient responsibility for the claim.
A subscriber and his or her dependents.
A list of generic and brand name drugs covered by a health plan under the outpatient prescription drug benefit.
A written or oral expression of dissatisfaction. Grievances include, but are not limited to, quality of care concerns and requests for review of coverage decisions.
The entity, usually an employer, that an insurance company enters into a group health plan contract with.
Group Health Plan
A health insurance plan that provides benefits for employees of a business or members of an organization, as opposed to individual and family health insurance.
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Health Insurance Portability and Accountability Act of 1996, federal legislation mandating specific privacy rules and practices for medical care providers and health insurance companies, designed to streamline industry practices and protect the privacy and identity of health care consumers.
Health Savings Account (HSA)
A tax-advantaged savings account designed to be used in conjunction with certain high-deductible health insurance plans to pay for qualifying medical expenses.
High-Deductible Health Plan (HDHP)
A high-deductible health plan usually includes a lower monthly premium than other plan designs, with higher deductible limits and is designed to be used in conjunction with a health savings account.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
Individual and Family Health Insurance
Health insurance purchased by an individual or family, independent of any employer group or organization.
Large Group Employer
California defines employers with 101 or more employees as large groups.
Major Medical Insurance
A term designating standard individual and family or group health insurance plans providing benefits for a broad range of health care services, both inpatient and outpatient.
Coverage for medical services associated with pregnancy and delivery.
A group of physicians and other providers who do business together and who provide or arrange for covered services.
Professional services of physicians and other health care professionals, including medical, surgical, diagnostic, therapeutic and preventive services.
Appropriate and necessary services for the diagnosis or treatment of a medical condition, in accordance with professionally recognized standards of care.
The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).
A subscriber or qualified dependent family member who is entitled to receive covered services.
The facilities, providers and suppliers a health insurer or plan has contracted with to provide health care services.
A health care provider who has a contractual relationship with a health insurance company. Among other things, this contractual relationship may establish standards of care, clinical protocols, and allowable charges for specific services.
Open Enrollment Period
The designated annual timeframe to enroll in a health plan. Outside the open enrollment period, enrollment in a health plan can occur if the member qualifies for a special enrollment period. Examples of eligibility for a special enrollment period include events such as getting married, having a baby or losing other health coverage. Each employer-based plan may have a different open enrollment period.
Health care costs that a patient or enrollee must pay for out of his or her own pocket, often including such costs as coinsurance, deductibles, etc.
Out-of-pocket Maximum (OOPM)
The maximum amount a member will be required to pay out-of-pocket in a single benefit year for most covered services, often including copayments coinsurance and deductibles, but not monthly premiums. Each family member has an annual OOPM; this is listed in their Summary of Benefits. For families with two or more members, the annual OOPM is reached either when the maximum is reached for any one member, or when the family reaches the family maximum.
The Patient Protection and Affordable Care Act, also referred to as Health Care Reform or the ACA, signed into law by President Obama in 2010, as well as any related rules, regulations or guidance.
A decision by a health plan that a member’s health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Health plans may require preauthorization for certain services before a member receives them, except in an emergency. Preauthorization isn’t a promise a health plan will cover the cost.
A premium is the dollar amount due to a member’s health plan each month for health care coverage. In most cases, employers pay part of the premium and members pay the rest, usually in the form of payroll deduction.
Medical care rendered not for a specific complaint but focused on prevention and early-detection of disease.
Preventive Care Services
Services that do one or more of the following:
- Protect against disease, such as in the use of immunizations
- Promote health, such as counseling on tobacco use
- Detect disease in its earliest stages before noticeable symptoms develop, such as screening for breast cancer
Primary Care Physician (PCP)
Some health insurance plans require a patient to choose a PCP. A PCP usually serves as a patient’s main health care provider and may refer a patient to specialists for additional services.
The process where a health plan or medical group reviews a request for specific health care services or products, resulting in a decision (based on applicable medical standards or criteria, regulatory requirements, plan benefits, etc.) to approve, modify or deny the requested service or item.
A term commonly used by health insurance companies to designate any health care provider, whether a doctor or nurse, hospital or clinic.
Rate Guarantee Period
The length of time that the insurance company guarantees a new member will not face any increase in his or her monthly health insurance premiums. Not all health insurance plans come with a rate guarantee period.
The process by which a patient is authorized by his or her PCP to a see a specialist or get certain medical services for the diagnosis or treatment of a specific condition.
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
A doctor who does not serve as a PCP but who provides secondary care in a specific medical field.
A health plan’s area of service that may include some or all ZIP codes within a specified county. The service area may be used to limit enrollment based on where people live or work. It is also generally the area where members can get routine (non-emergency) services.
Small Group Employer
California defines employers with at least one, but no more than 100, employees as small groups.
A member who is eligible for membership on his or her own behalf and not by virtue of dependent status and who meets the eligibility requirements as a subscriber.
Summary of Benefits and Coverage (SBC)
The SBC summarizes key features of the plan or coverage, such as covered benefits, cost-sharing provisions, and coverage limitations and exceptions.
Medically necessary services for a condition that requires prompt medical attention but is not an emergency medical condition.
This glossary is for informational use only. In the event of any discrepancies in information, the SHP Evidence of Coverage (EOC) and incorporated Benefits and Coverage Matrix (BCM) determine coverage and costs.