A request for reconsideration of a previous decision or adverse determination of a request for a healthcare service, supply or device for a member. A member may submit an appeal verbally or in writing. The member's authorized representative or the member's participating provider can also submit an appeal on behalf of the member.
Behavioral Health Treatment
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.
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).
Health Plan Benefits and Coverage Matrix (BCM)
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 additional provisions of the benefits offered by Sutter Health Plus.
A request for payment that a member or their healthcare provider submits to the health plan.
A percentage of the cost of a covered service members must pay. If a plan includes coinsurance, members will see the percent listed in their Healthcare Benefits and Coverage Matrix (BCM).
A specific dollar amount members pay each time they see a participating provider or receive certain covered services as described in the Healthcare Benefits and Coverage Matrix (BCM). 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). This does not include costs for premiums.
Covered California, HBEX, Health Benefit Exchange, Health Exchange
The public health insurance marketplace that helps individuals, families, and small businesses shop for and enroll in healthcare coverage. In California, this marketplace is Covered California.
The prescription drug coverage for a particular plan design is expected to pay on average as much as the standard Medicare Part D prescription drug coverage in accordance with the Centers for Medicare and Medicaid Services (CMS).
The amount members must pay in a benefit year for certain covered services before the health plan 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 healthcare provider for everyday or extended use. Coverage for DME may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Emergency Medical Condition
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected by the member to result in any of the following:
- Placing the member’s health in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
An emergency medical condition is also “active labor,” which means a labor when there is inadequate time for safe transfer to a participating hospital (or designated hospital) before delivery or if transfer poses a threat to the health and safety of the member or unborn child.
A psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the member as being one either of the following:
- An immediate danger to themselves or to others
- Immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder
The portion of health plan premium paid by the employee, usually deducted from wages by the employer.
The portion of an employee’s monthly health plan premium paid for by the employer.
The process through which an approved applicant or employee and their eligible dependents are registered as members of a health plan.
Evidence of Coverage and Disclosure Form (EOC)
The document that describes how, when and where a member can access covered healthcare services. In addition, it describes the limitations and exclusions provided for under the plan, how a member 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 plan will not provide coverage.
Explanation of Benefits
A statement sent to a member listing what services were billed by a healthcare provider, how those charges were processed and the member’s total financial responsibility for the claim.
A subscriber and all of their dependents.
The complete list of self-administered, FDA-approved, outpatient prescription drugs evaluated by the Sutter Health Plus Pharmacy and Therapeutics Committee for use and eligible for coverage under the Sutter Health Plus health plan. The formulary is also known as a prescription drug list.
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, with which a health plan enters into a group health plan contract.
Group Health Plan
A health plan offered by an employer or employee organization that provides health coverage to employees and their dependents, as opposed to individual and family health coverage.
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 healthcare consumers.
Healthcare 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 Savings Account (HSA)
A type of savings account that lets a member set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in an HSA to pay for deductibles, copayments, coinsurance, and some other expenses, a member may be able to lower their overall healthcare costs. HSA funds generally may not be used to pay premiums.
High-Deductible Health Plan (HDHP)
An HDHP has a higher deductible than a traditional health plan. The monthly premium is usually lower, but a member will pay more healthcare costs before the health plan starts to pay its share. An HDHP is designed to be used in conjunction with a health savings account.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
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.
Individual and Family Plan
Healthcare coverage 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.
An essential health benefit (EHB) that provides medical coverage for inpatient and outpatient services associated with pregnancy, labor and delivery and newborn care.
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 healthcare 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 healthcare services.
A contracted medical group, participating physician, participating hospital or other licensed health professional or licensed health facility or other health professional otherwise authorized under California law to practice their profession in the State of California who or which, at the time care is provided to a member, has a contract in effect with Sutter Health Plus to provide covered services to members.
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.
Healthcare costs that aren’t reimbursed by a member’s health plan. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.
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, excluding health plan premiums. Each member has an annual OOPM; listed within their Benefits and Coverage Matrix (BCM). For families with two or more members, the annual OOPM for each family member is satisfied either when the maximum individual amount is reached by that family member, or when a combination of individual family member amounts reaches the family maximum amount.
The Patient Protection and Affordable Care Act and any rules, regulations, or guidance issued thereunder.
A decision by a health plan that a member’s healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called preauthorization, prior approval or precertification. Health plans may require prior authorization for certain services before a member receives them, except in an emergency. Prior authorization 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 healthcare coverage. In most cases for employer-based plans, employers pay part of the premium and members pay the rest, usually in the form of payroll deduction.
Preventive Care (Preventive Service)
Routine healthcare, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems.
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)
A PCP directly provides or coordinates a range of healthcare services for a patient, including referring a patient to specialists for additional services.
An individual or facility that provides healthcare services. Some examples of a provider include a doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, etc.
Rate Guarantee Period
The length of time that the health plan guarantees a new member will not face any increase in his or her monthly health plan premiums. Not all 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.
Healthcare 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 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, employee(s) as small groups.
A doctor who does not serve as a PCP but who provides secondary care in a specific medical field.
A member who is eligible for membership on their own behalf and not by virtue of dependent status and who meets the eligibility requirements as a subscriber.
Summary of Benefits and Coverage (SBC)
A summary that lists clear comparisons of costs and coverage between health plans. People can compare options based on price, benefits, and other features that may be important to them. Members get the SBC when they shop for coverage on their own or through their employer, renew or change coverage, or request an SBC from the health plan.
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 Sutter Health Plus Evidence of Coverage (EOC) and incorporated Benefits and Coverage Matrix (BCM) determine coverage and costs.