Helpful Definitions




	Health insurance, like any complicated subject, has its share of technical terms and abbreviations. To help, we've provided you with easy to understand definitions of some of the more common words and phrases used in talking about the subject.

	Click on the term of the first letter you're looking for.

	A B C D E F G H I J K L M N O P Q R S T U V W X YZ



		A



		Annual deductible: The amount you pay for covered expenses first, before an insurance plan begins to pay benefits. Some plans require deductibles for all services, some for just certain types of services; others require no deductible at all. [ Back to Top ]



		B



		Board Certified*: This designates that the provider is Board Certified by the American Board of Medical Specialties (ABMS) in that particular specialty. The intent of the certification of physicians is to provide assurance to the public that a physician specialist certified by a Member Board of the ABMS has successfully completed an approved educational program and evaluation process which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty. [ Back to Top ]



		C



		CaliforniaCare (HMO) Ready Access Program: Some CaliforniaCare (HMO) Medical Groups (PMG's and IPA's) participate in the Ready Access program. The Ready Access program consists of 2 parts, Direct Access and Speedy Referral. A PMG or IPA may participate in one or both parts of the Ready Access program. Speedy Referral: allows your PCP to make expedited referrals to any one of the following 15 areas of specialty: Cardiology, Dermatology, Endocrinology, ENT (Otolaryngology), Gastroenterology, General Surgery, Hematology, Neurology, Oncology, Ophthalmology, Orthopedic Surgery, Podiatry, Routine Laboratory, Routine X-Ray and Urology. Direct Access: allows you, the member, to self-refer to one of the following 3 areas of specialty: Allergy/Immunology, ENT (Otolaryngology) and Dermatology. Please verify each specialist's status with your Medical Group prior to making an appointment, as the physician's status is subject to change. co-pay/co-insurance: The flat amount or percentage you pay for a covered service after you satisfy the annual deductible, if any. covered expenses:Charges for services which are medically necessary and eligible for payment under the plan. A covered expense can be no more than the maximum amount stated in the plan. [ Back to Top ]



		D



		drugs, formulary: Drugs which the medical literature indicates are clinically effective, safe and of reasonable cost. The goal of our formulary list of prescription drugs, as established for the WellPoint Pharmacy Plan, is to identify and promote prescription drugs which are therapeutically appropriate and cost-effective. drugs, non-formulary: Prescription drugs not on our formulary list. [ Back to Top ]



		E



		emergency:A sudden, serious or unexpected acute illness, injury or condition which could permanently endanger your health if medical treatment is not received immediately. [ Back to Top ]



		G



		group insurance:A single policy issued to an employer under which employees and their eligible family members may be covered. Each employee receives a certificate of coverage outlining his/her health plan benefits. [ Back to Top ]



		H



		HMO (Health Maintenance Organization):An organization that provides a wide range of comprehensive health care services through a designated group, or network of doctors, hospitals, labs and other providers. To receive benefits, you must see the doctor you select as your primary care physician first for care or a referral, except in the case of an emergency. Your choice of doctors is restricted to those in the network. hospitals, non-contracting:Hospitals that are not part of the Prudent Buyer network and that have not signed a standard contract with us are considered non-contracting hospitals. We do not pay benefits for services provided by non-contracting hospitals except in the case of a medical emergency. hospitals, participating :Effective May 1, 1996, Prudent Buyer (PPO) members admitted to Hospitals that have a PARTICIPATING Hospital status may require an additional co-payment as determined by your contract hospitals, preferred-participating:Prudent Buyer (PPO) members admitted into Hospitals with a PREFERRED Participating status will not have any additional co-payment amounts for services rendered. [ Back to Top ]



		I



		(IPA) Independent Physicians Association:Primary Care Physicians (PCP) who practices in his/her own office, but is part of a larger network of many physicians. They will refer you to a specialist, usually close by, or to a medical lab for special work. individual insurance: Health care coverage for individuals or single family units. [ Back to Top ]



		L



		limited fee schedule: A list of maximum amounts we will pay for certain services provided by non-network providers. You are responsible for paying your co-insurance and any amount over the limited fee schedule. [ Back to Top ]



		N



		negotiated fee: The discounted rates that Prudent Buyer network doctors and hospitals agree to charge for covered expenses. network/ in-network: The term used for services received from doctors, hospitals and other providers contracting with us to provide care at the negotiated fee and to handle the paperwork. [ Back to Top ]



		O



		out-of-network/non-network: The term used for services received from doctors, hospitals or to the providers that are not part of the network. You pay substantially more for out-of-network services. out-of-pocket maximum: The most you pay for covered expenses during the year before the plan begins paying 100% of covered expenses for the rest of the year. Only covered expenses count toward the maximum. For example, any charges above the limited fee schedule for out-of-network doctor's services do not count. [ Back to Top ]



		P



		PCP (Primary Care Physician):The doctor who serves as your CaliforniaCare (HMO) health care manager and coordinates virtually all of the health care services you receive. Your PCP provides you with routine medical care and refers you to a specialist if necessary. PMG (Participating Medical Group): A group of doctors, both primary care physicians and specialists, who are practicing in one location to provide health care services. Most medical services, including special exams, X-Ray and laboratory tests are available in one convenient location. PPO (Preferred Provider Organization): Health care providers who are under contract to provide care at discounted or fixed fees. Unlike HMOs, health plans with a PPO allow you to choose any doctor at any time. However, if you select a non-PPO provider you will pay more out of pocket for services than you would if you selected a PPO "network" provider. Pre-existing condition or pre-existing waiting period: If you receive medical advice, or treatment was recommended or received for any accident, illness, or other medical condition during six months before you enroll in a plan, you won't be covered for the care you receive as a result of that condition until you've been enrolled in the plan for six months. If you satisfied the six-month waiting period while enrolled in another medical plan, and enrolled within 30 days of completing that waiting period, you won't need to complete another pre-existing waiting period. You will receive partial credit if you were insured under another plan for less than six months. Prudent Buyer PPO: The Preferred Provider Organization. [ Back to Top ]



		Q



		Qualifying prior coverage:Any individual or group plan that provides medical, hospital, and surgical coverage, including continuation or conversion coverage or coverage under a publicly sponsored program such as Medicare or Medicaid. It does not include accident only, credit, disability income, Medicare supplement, long term care insurance, dental, vision, workers' compensation insurance, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans. [ Back to Top ]



		S



		Specialist:a physician whose practice is limited to a particular branch of medicine or surgery. NOTE: CaliforniaCare (HMO) plan members will not be eligible for any CaliforniaCare benefits for services received by any unauthorized specialist. If your Primary Care Physician (PCP) feels that a specialist is needed to treat your condition, your PCP will refer you to the appropriate specialist. Your PCP will also prepare a Referral Authorization Form if you must see a specialist that is not in your Medical Group. However, if your PMG or IPA participates in Direct Access and you have verified a specialists's status with your Medical Group prior to making an appointment, you will be eligible for benefits. stop loss: See "out-of-pocket maximum" [ Back to Top ]