Glossary

A - B - C - D - E - F - G - H - I - L - M - N - O - P - Q - R - S - T - U - V - W - Y

Note: clicking links below to the "ACA Uniform Glossary" will open a new browser window to a document on the Center for Medicare & Medicaid Services (CMS) website. The Affordable Care Act requires insurance carriers to use this glossary for common health insurance terms.

A

ACA: Affordable Care Act, the healthcare reform law enacted in 2010. This term is short for PPACA, or the Patient Protection and Affordable Care Act, and is sometimes referred to as Obamacare.

Access: A patient's ability to obtain medical care. The ease of access is determined by components such as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation, and cost of care.

Accreditation: Formal recognition by an agency or organization that independently evaluates and recognizes a program of study or an institution as meeting certain predetermined standards; may be either permanent or for a specified time period.

ACSW: Academy of Certified Social Workers

Actuary: A person in the insurance field who determines insurance policy rates and conducts various other statistical studies.

ADD: Attention Deficit Disorder

Administrative Services Only (ASO) contract: A contract between an insurance company and a self-insured plan where PacificSource performs administrative services only (e.g.; claims processing); used synonymously with the terms "self-funded" and "partially self-funded" plans. The client (employer) is totally at risk for claims.

Adjudication: Processing a claim through a series of edits to determine proper payment.

Adverse selection: The tendency for a person in poor health to be more likely than one in good health to enroll in a health plan.

Allied Health Professional (AHP): All healthcare providers who are not licensed as doctors of medicine or osteopathy. Examples include nurse practitioners, physician assistants, and chiropractors.

Allowed amount: Please see ACA Uniform Glossary.

Alternative care: (1.) Medical care received in lieu of inpatient hospitalization. Examples include outpatient surgery, home healthcare, and skilled nursing facility care. (2.) Nontraditional care delivered by providers such as midwives, acupuncturists, naturopaths, massage therapists, and chiropractors.

AMA: American Medical Association

Ambulatory care: Health services rendered in a hospital's outpatient facility, physician's office, or home setting; often used synonymously with the term "outpatient care."

Ancillary medical services: Covered services that supplement care furnished by primary care or specialist physicians. Examples of ancillary services include ambulance service, ambulatory surgery, durable medical equipment, imaging services, laboratory services, pharmaceuticals, and physical or occupational therapy.

Appeal: Please see ACA Uniform Glossary.

ARRA: The American Recovery and Reinvestment Act is also referred to as an economic stimulus bill. On February 17, 2009, President Obama signed the Act, which includes several provisions related to healthcare. In part, the Act creates new opportunities for individuals to qualify for continuation coverage provided by a group health plan. The Act also provides for a subsidy for that continuation coverage for some individuals and their family members.

ASO: See Administrative Services Only.

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B

Balance billing: Please see ACA Uniform Glossary.

Behavioral healthcare: Treatment of mental health and substance abuse disorders.

Beneficiary: A person designated by a participant or by the terms of a plan who is or may become entitled to a benefit under the plan.

Benefit package: Specific services provided by the insurance carrier.

Benefit plan: Covered services, copayments or deductible requirements, and limitations and exclusions contained in the contract between PacificSource and a policyholder.

BHP: Oregon Basic Health Plan

BME: Board of Medical Examiners. Responsible for administering the Medical Practice Act and establishing the rules and regulations pertaining to the practice of medicine in Oregon.

Board certified: A physician who has passed an examination given by a medical specialty board.

Board eligible: A physician who has graduated from an approved medical school and is eligible to take a specialty board examination.

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C

CAC: Certified Alcoholism Counselor

Cafeteria plan: A flexible benefit plan (as defined by Section 125 of the Internal Revenue Code) offered by many employers in which the participants (employees) may choose between cash and certain "qualified benefits." The list of qualified benefits may include medical coverage, healthcare flexible spending arrangements, life insurance, disability coverage, vacation days, and dental care. Employees who don't want a particular benefit can spend more on another benefit, or potentially receive the difference in cash.

Call share: When providers agree to provide back-up coverage for another provider during times they are unavailable.

Call share group: A group of providers with similar specialties who have joined together to provide call share services.

Capitation: A method of paying for medical services on a per-person rather than a per-procedure basis. Under capitation, PacificSource pays a participating doctor a fixed amount per month for every PacificSource member they take care of, regardless of how much or little care the member receives.

Carrier: Insurer; insurance company; underwriter of risk.

Carve-out: An arrangement where an employer or health plan removes (or "carves out") coverage for a specific category of services, such as mental health/substance abuse, vision care, or prescription drugs. The carved-out services are then excluded from coverage under the health plan, and typically the employer or health plan arranges for coverage through a contract with a separate set of providers. The health plan's contract with these providers may specify certain payment and utilization management arrangements.

Case management: The process whereby a healthcare professional supervises the administration of medical or ancillary services to a patient. Case management is typically used for members who have a catastrophic disorder or are receiving mental health services. Case managers are thought to reduce the costs associated with the care of such patients, while providing high-quality medical services.

Case rate: "Package price" for a specific procedure or diagnosis-related group. PacificSource often negotiates case rates with providers and facilities for high-cost medical services such as transplants.

CDHP: See Consumer-Directed Health Plan.

Centers for Medicare & Medicaid Services (CMS): Formerly known as the Health Care Financing Administration (HCFA), this is the federal agency responsible for administering Medicare and overseeing states' administration of Medicaid and the Office of Prepaid Healthcare Operations and Oversight (OPHCOO), which in turn oversees Health Maintenance Organizations (HMOs).

Certificate of Creditable Coverage (COC): Under HIPAA, a certificate that must be furnished by group health plans and health insurance issuers to individuals who lose coverage under employer-provided group health plans and under certain individual policies. The certificate documents the individual's creditable coverage.

CHIP: Children's Health Insurance Program. This is a federal program that provides health coverage to children in families with incomes too high to qualify for Medicaid but who can't afford private coverage.

CHAMPUS: Civilian Health and Medical Program of the Uniformed Services

Claim: Information submitted by a provider or a member to establish that medical services were provided to a member from which processing for payment to the provider or member is made. The term generally refers to the liability for healthcare services received by members.

Clinic: Healthcare facility that provides preventive, diagnostic, and treatment services to patients in an outpatient setting.

Closed panel: A primary care practitioner who is not accepting new patients.

CMS: See Centers for Medicare & Medicaid Services.

CNM: Certified Nurse Midwife

COB: Coordination of Benefits

COBRA: Acronym for Consolidated Omnibus Budget Reconciliation Act, a federal law that requires employers to offer continued health insurance coverage to employees whose health and dental insurance coverage terminates. COBRA applies only to groups of 20 or more employees; groups with fewer than 20 employees are subject to state continuation laws.

COC: See Certificate of Creditable Coverage.

Co-insurance: Please see ACA Uniform Glossary.

Complaint: An expression of dissatisfaction about a specific problem encountered by a member, or about a decision by the insurer (or agent acting on behalf of the insurer). A complaint must include a request for action to resolve the problem or change the decision.

Complications of pregnancy: Please see ACA Uniform Glossary.

Consumer-Directed Health Plan (CDHP): A health plan that allows beneficiaries more direct control over medical decisions and costs. Typically, this type of plan consists of several tiers—a health spending account (see HSA) funded by the employer and that can be rolled over from year to year. Generally, a "defined contribution," such as a specific dollar amount is placed in this account by the employer for the employee. The deductible is funded by the employee and used after the health spending account is exhausted; health insurance is triggered after the deductible is met. Employees also may fund medical reimbursement accounts to pay for their share of expenses.

Coordination of Benefits (COB): An insurance provision that applies to people with insurance coverage under more than one plan. Under COB, the insurance carriers work together to determine responsibility for payment so that covered expenses are paid with little or no out-of-pocket cost to the member. When benefits are coordinated, one plan pays benefits first (the "primary coverage") and the other pays based on the remaining balance (the "secondary coverage").

Co-payment: Please see ACA Uniform Glossary.

Cost containment: A strategy that aims to reduce healthcare costs and encourages cost-effective use of services.

Cost sharing: When a member is responsible for paying a portion of the cost of care via deductibles, copayments, or coinsurance.

Coverage: Services or benefits provided through a health insurance plan.

Covered employee: Under COBRA, an individual who is (or was) provided coverage under a group health plan because of his or her performance of services for the employer maintaining the plan.

Covered lives: Total number of insured members.

CPT: Current Procedural Terminology. Systematic listing and numeric coding of procedures used to identify medical services provided in a professional or hospital setting.

Credentialing: Examination of a healthcare provider's professional credentials to determine whether the provider should be entitled to clinical privileges at a hospital or to a contract with a healthcare organization.

Creditable coverage: Under HIPAA, the period of an individual's coverage under a group health plan, health insurance, Medicare, or any one of several other specified health plans or health insurance sources that is not interrupted by a 63-day break in coverage.

CRNA: Certified Registered Nurse Anesthetist

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D

DAW: Dispense As Written

DBA: Doing Business As

Deductible: Please see ACA Uniform Glossary.

Dependents: Family members of the subscriber who are eligible for coverage on the subscriber's plan.

Diagnosis: The identification of a disease or condition through examination.

Diagnosis-Related Groups (DRG): A program in which hospital procedures are rated in terms of cost and intensity of services delivered. When insurers contract to reimburse hospitals based on DRG, they pay a standard rate per procedure regardless of the hospital's cost to provide that service.

Disability: A medical condition that results in functional limitations that interfere with a person's ability to perform their normal work and results in limitations in major life activities.

Disclaimer: A form providers may ask members to sign indicating the member understands he/she may be financially responsible for charges incurred during the visit. Disclaimer forms are typically used when managed care members obtain care from someone other than their designated primary care practitioner (PCP) without a referral.

Disenrollment: Termination of an employee's healthcare coverage, whether voluntary or involuntary.

DME: See Durable Medical Equipment.

DO: Doctor of Osteopathy

DOB: Date of Birth

Domestic Partner: An individual's unmarried partner of the same or opposite sex.

DRG: See Diagnosis-Related Groups.

Dual Choice or Dual Option: The choice between two or more different arrangements for medical care. For example, an employer may maintain two plan designs, and offer its employees a choice of enrolling in a Preferred plan or a Prime plan.

Durable Medical Equipment (DME): Please see ACA Uniform Glossary.

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E

EAP: Employee Assistance Program

EBSA: The Employee Benefits Security Administration, formerly known as the Pension and Welfare Benefits Administration (PWBA). EBSA is an agency of the U.S. Department of Labor.

EDI: Electronic Data Interchange

EFT: See Electronic Funds Transfer

EHB: See Essential health benefits.

Election period: The period of time allotted for a person to make coverage decisions, such as opting in or out of a plan.

Electronic Remittance Advice (ERA): The ability to send electronic explanation of benefits directly to the provider.

Electronic Funds Transfer (EFT): The ability to make electronic claims payments directly to the provider's bank account.

Electronic Payment Card: A debit card, stored value card, or credit card that allows a participant to access funds in a health FSA, health savings account, or health reimbursement arrangement to pay the service provider at the point-of-sale (i.e., the time a service or item is provided).

Eligibility Requirements: The age, service, and other requirements specified by a plan document as pre-conditions to an employee's participation.

Emergency medical condition: Please see ACA Uniform Glossary.

Emergency medical screening exam: The medical history, examination, ancillary tests, and medical determinations required to ascertain the nature and extent of an emergency medical condition.

Emergency medical transportation: Please see ACA Uniform Glossary.

Emergency room care: Please see ACA Uniform Glossary.

Emergency services: Please see ACA Uniform Glossary.

Employee Retirement Income Security Act of 1974 (ERISA): Regulates the majority of private pension and welfare group benefit plans (includes health plans) in the U.S.

Enrolled group: A business or other organization covered under a group insurance policy.

Enrollee: Person eligible for services as either a subscriber or covered dependent. "Member" is synonymous with "enrollee."

Enrollment: Process by which an individual becomes covered under a health or dental plan.

EOB: Explanation of Benefits

EOP: Explanation of Payment

Episode of care: All treatment rendered in a specified time frame for a specific disease.

ER: Emergency Room

ERA: See Electronic Remittance Advice.

ERISA: See Employee Retirement Income Security Act of 1974.

Essential Health Benefits (EHB): A set of health care service categories that must be covered by certain plans, starting in 2014 as part of the Affordable Care Act. See Healthcare.gov for more information.

Exchange: An online marketplace where individuals and small employers can purchase health insurance for coverage that begins in 2014. Buying health insurance in an exchange is optional; however, most federal assistance to help individuals and families pay for health insurance is only available through an exchange.

Excluded services: Please see ACA Uniform Glossary.

Experimental procedures: Services, supplies, treatments, or drug therapies that the health plan has determined are not generally accepted as effective in treating the illness for which their use is proposed. Also called investigational or unproved procedures.

Extended care facility: A nursing home type of setting that offers skilled, intermediate, or custodial care.

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F

Fee schedule: List of fees for specified medical procedures.

Flexible Spending Account (FSA): An employee benefit offered by many companies that allows employees to have pretax dollars withheld from their salaries to pay for unreimbursed medical expenses and dependent-care expenses, such as babysitting or eldercare.

FMLA: Family Medical Leave Act

Form 5500: The form for the annual report required to be filed for various employee benefits plans.

Formulary: A list of preferred generic and name brand medications used to treat various medical conditions.

FSA: See Flexible Spending Account.

FTE: Full-time Employee

FTS: Full-time Student

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G

Gatekeeper: See Primary Care Practitioner (PCP).

Global: All-inclusive. For example, a "global surgery" includes the surgery plus all pre-op and post-op care, or a "global billing" may include all charges for a series of treatments.

Grievance:  Please see ACA Uniform Glossary.

Group Health Plan: Generally, a plan maintained by an employer or an employee organization that provides medical care to employees or their dependents, directly or through insurance, reimbursement, or otherwise. The specific definition differs depending on the federal statute at issue.

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H

Habilitation services: Please see ACA Uniform Glossary.

HCFA: Health Care Financing Administration

HCFA 1500: A universal billing form developed by HCFA.

HCPCS, HCFA: Common Procedural Coding System; an alphanumeric coding system developed by the Health Care Financing Administration to cover miscellaneous services, supplies, drugs, and procedures not found in Current Procedural Terminology (CPT).

HDHP: See High Deductible Health Plan.

Health FSA: A flexible spending arrangement under which participants may obtain reimbursement for medical expenses that cannot be reimbursed through insurance or any other arrangement (e.g., co-payments, deductibles, eyeglasses, orthodontia).

Health insurance: Please see ACA Uniform Glossary.

Health Insurance Portability and Accountability Act (HIPAA): Far-reaching federal legislation designed to improve the portability of health coverage, reduce healthcare costs by standardizing the processing of healthcare transactions, increase the security and privacy of healthcare information, and to make other changes to the healthcare delivery system.

Health Maintenance Organization (HMO): A legal entity or organized system of healthcare that provides directly or arranges for a comprehensive range of basic and supplemental healthcare services to a voluntarily enrolled population in a geographic area on a primarily prepaid and fixed periodic basis. Informal definition: a health insurer that tries to reduce the costs of healthcare by managing members' access to services, usually through use of a primary care practitioner (PCP) and referrals for specialist care. Although technically incorrect, the term "HMO" is frequently used synonymously with "health insurer."

Health Reimbursement Arrangement (HRA): An IRS-approved, tax-favored benefit that reimburses employees, up to a maximum dollar amount, for qualified medical care expenses not reimbursed by an employer's health plan. HRAs are paid for solely by the employer. Any unused portion of the maximum dollar amount at the end of a coverage period may be carried forward to increase the maximum reimbursement amount in subsequent coverage periods.

Health Savings Account (HSA): A tax-sheltered savings account that may be used by beneficiaries covered by qualified high deductible health plans to pay for health care expenses not covered by their health plan. Money remaining in the account at the end of the year may be used in the following year. Contributions to an individual's HSA can be made by anyone, including the employer, up to an annual maximum.

HHS: U.S. Department of Health and Human Services

High Deductible Health Plan (HDHP): A low-cost plan design that meets government regulations regarding the deductible and out-of-pocket costs. Often paired with a Health Savings Account (HSA). 

HIPAA: See Health Insurance Portability and Accountability Act.

HMO: See Health Maintenance Organization.

Home health care: Please see ACA Uniform Glossary.

Hospice services: Please see ACA Uniform Glossary

Hospitalization: Please see ACA Uniform Glossary.

Hospital outpatient care: Please see ACA Uniform Glossary.

HRA: See Health Reimbursement Arrangement.

HSA: See Health Savings Account.  

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I

IBNR: See Incurred But Not Reported.

ICD or ICD-9-CM: International Classification of Diseases, 9th Edition (Clinical Modification); book of narrative/numeric codes used by healthcare providers to classify medical diagnoses.

Incurred But Not Reported (IBNR): Covered expenses that have been incurred by an insured for which the insurance carrier has not yet received claims. Reserves are accumulated by the insurance company to cover IBNRs.

Indemnity: An insurance program in which the insured person is reimbursed for covered expenses.

Individual Insurance Market: The market for health insurance coverage offered to individuals other than through a group health plan. The term also includes (subject to contrary election by the state involved) the market for coverage offered in connection with a group health plan that has fewer than two participants who are current employees.

IPA: "Independent Physician Association" or "Individual Practice Association." Both are associations of physicians in independent practice who as a collective unit enter into contracts with health insurers to provide medical services.

In-network co-insurance: Please see ACA Uniform Glossary.

In-network co-payment: Please see ACA Uniform Glossary.

Inpatient: An individual who has been admitted to a hospital as a registered bed patient and is receiving services under the direction of a physician for at least 24 hours.

Inpatient care: Care provided in a licensed bed in a hospital, nursing home, or other medical or psychiatric institution.

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L

Late Enrollee: Under HIPAA, an individual who enrolls in a group health plan after the first available enrollment period, other than an individual who is a special enrollee.

LCP: Licensed Clinical Psychologist

LCSW: Licensed Clinical Social Worker

Look Back Rule: Under HIPAA, a rule limiting preexisting condition exclusions to conditions for which medical advice, diagnoses, care, or treatment was recommended or received within the six-month period ending on the individual's enrollment date.

Look Forward Rule: Under HIPAA, a rule limiting the application of preexisting condition exclusions to the 12-month period (or the 18-month period, for late enrollees) after the enrollment date under a group health plan. The 12-month (or 18-month) period is reduced by the period of any creditable coverage under any previous plan.

LPC: Licensed Professional Counselor

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M

MAC: Maximum Allowable Cost

Managed care: A system of healthcare delivery developed to manage the cost, quality, and access of that care. It is characterized by a contracted panel of providers, use of a primary care practitioner, limitations on benefits provided by noncontracted providers, and a referral authorization system for care provided by someone other than the primary care practitioner.

Maximum Coverage Period: Under COBRA, the maximum period for which COBRA coverage must be offered for a particular qualifying event.

MD: Medical Doctor

Medicaid: The federal-state health insurance program for low-income U.S. citizens. Medicaid also covers nursing-home care for the indigent elderly.

Medical group: A group of physicians organized as a single professional entity that is recognized under state law as an entity to practice a medical profession, and which has entered into a contract with PacificSource to provide covered services to members.

Medically necessary: Please see ACA Uniform Glossary.

Medicare: The federal health insurance program for older U.S. citizens and the disabled.

Member: Any PacificSource subscriber or dependent as determined by PacificSource.

Mental Health and Chemical Dependency Parity: Oregon's mental health parity law became effective January 1, 2007. It requires group health insurance policies to cover treatment of chemical dependency and mental or nervous conditions at the same level and with no more restrictions than those imposed for other medical conditions.

MRI: Magnetic Resonance Imaging

MSW: Masters in Social Work

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N

National Medical Support Notice: A standardized medical child support order that is used by state child support enforcement agencies to obtain coverage for children under group health plans.

NDC: National Drug Code or National Data Corporation

Network: Please see ACA Uniform Glossary.

Noncovered services: Those services excluded from coverage by PacificSource.

Nonemergent condition: Defined as routine physical or eye examinations, diagnostic work-ups for chronic conditions, routine prenatal care, elective surgery, and scheduled follow up visits for prior emergency conditions. In these instances, no benefits are payable for service/treatment provided in an emergency room setting.

Nonformulary covered prescriptions: A list of prescription drugs that carry a higher copay.

Nonpreferred/Nonparticipating provider: Please see ACA Uniform Glossary.

Nurse practitioner: A registered nurse who has advanced skills in the assessment of physical and psychosocial health status of individuals, families, and groups.

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O

Obamacare: See ACA.

Open Enrollment: An annual period, usually occurring shortly before the beginning of a new plan year, during which employees can enroll for benefits and change their elections under the employer's plan.

OTC: See Over-the-Counter Drug or Medicine.

Out-of-area: That area that is outside PacificSource's service area.

Out-of-network co-insurance: Please see ACA Uniform Glossary.

Out-of-network co-payment: Please see ACA Uniform Glossary.

Out-of-panel provider: A provider who is not a part of the managed care panel.

Out-of-pocket limit (OOP): Please see ACA Uniform Glossary.

Outpatient: A person who visits a clinic, emergency room, or health facility and receives healthcare without being admitted as an overnight patient.

Outpatient care: Care given a person that does not require a stay in a licensed hospital or nursing home bed.

Over-the-Counter (OTC) drug or medicine: A drug or medicine that is sold lawfully without a prescription.

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P

PacificSource Service Area: The geographic area where PacificSource markets its products and services.

Parity: See Mental Health and Chemical Dependency Parity.

Participating provider panel: An IPA link to term or other association of providers organized as a single professional entity, which enters into a service agreement with PacificSource for the provision of certain covered services to PacificSource members.

PBM: Pharmacy Benefit Manager

PCP: See Primary Care Practitioner

PDL: See Preferred Drug List

PHI: See Protected Health Information.

PHO: Physician Hospital Organization; Physicians and a hospital joining together to negotiate contracts with insurance carriers.

Physician: A person duly licensed and qualified to practice medicine in the state where his/her practice is located.

Physician assistant: A healthcare professional certified to perform certain duties such as history taking, diagnosis, drawing blood samples, urinalysis, and injections under the supervision of a physician.

Physician-Hospital Organization (PHO): A healthcare delivery organization including both physicians and a hospital or hospitals which has entered into a contract with PacificSource to provide certain specified covered services to members.

Physician services: Please see ACA Uniform Glossary.

Plan: Please see ACA Uniform Glossary.

Plan administration: Management of a plan, including accounting, billing, personnel, marketing, legal services, purchasing, and servicing of accounts.

Plan Year: The 12-month period on which a plan's records are maintained. The period must be described in the Summary Plan Description.

Point of Service (POS): A health plan allowing the covered person to choose to receive a service from a participating or nonparticipating provider, with different benefit levels associated with the use of participating providers, with or without a referral.

Policyholder: The employer or individual to which a contract is issued and in whose name a policy is written. In a plan contracting directly with the individual or family, the policyholder is the individual to whom the contract is issued.

Portability: Access to continuous health coverage so that the insured does not lose insurance coverage due to any change in health or personal status (such as employment, marriage, or divorce).

POS: See Point of Service.

PPACA: Patient Protection and Affordable Care Act, federal legislation inacted in 2010. This is also referred to as ACA or Obamacare.

PPO: See Preferred Provider Organization

Preauthorization: Please see ACA Uniform Glossary.

Pre-existing condition: Physical condition of an insured person that existed before the issuance of a policy or enrollment in a plan. Pre-existing conditions may result in a limitation in the contract on coverage or benefits.

Preferred Drug List (PDL): A list of brand name prescription medicines that is more limited than a standard drug formulary. Drugs on the list are selected based on clinical results and economic value.

Preferred provider: Please see ACA Uniform Glossary.

Preferred Provider Organization (PPO): Fee-for-service indemnity product where participants have financial incentives to seek care from participating providers, but are allowed to go to nonpar providers at a reduced benefit.

Premium: Please see ACA Uniform Glossary.

Prescription drug coverage: Please see ACA Uniform Glossary.

Prescription drugs: Please see ACA Uniform Glossary.

Preventive care: An approach to healthcare which emphasizes preventive measures such as routine physical exams, diagnostic tests, immunization, etc.

Primary care: Routine medical care, normally provided in a doctor's office. Professional and related services administered by an internist, family practitioner, obstetrician-gynecologist, pediatrician, or nurse practitioner in an ambulatory setting, with referral to secondary care specialists as necessary.

Primary care physician (PCP): Please see ACA Uniform Glossary.

Primary care provider (PCP): Please see ACA Uniform Glossary

Protected Health Information (PHI): Under HIPAA, link to term Individually Identifiable Health Information that is maintained or transmitted in any form or medium by a covered entity or its Business Associate, as further defined in 45 CFR Section 160.103.

Protocol: Description of a course of treatment or established practice pattern.

Provider: A person licensed, certified, or otherwise authorized or permitted by laws of this state to administer medical or mental health services in the ordinary course of business or practice of a profession (as defined in SB21). PacificSource further defines providers as physicians, dentists, nurses, pharmacists, and other healthcare facilities or entities including, for example, individual practice associations or medical groups engaged in the delivery of healthcare services. To the extent required by applicable law, providers are licensed and/or certified according to federal and/or state law.

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Q

Qualifying Event: Under COBRA, a triggering event that causes a loss of coverage under a group health plan.

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R

Reconstructive surgery: Please see ACA Uniform Glossary.

Referral: The process by which the member's primary care practitioner directs the member to seek and obtain covered services from other providers.

Referral authorization: The processes for reviewing and authorizing referrals to specialist physicians by primary care practitioners.

Rehabilitation services: Please see ACA Uniform Glossary.

Reinsurance: Insurance purchased by a carrier from another insurance company to protect itself against all or part of the losses that may be incurred by claims for its members (e.g., catastrophic care).

Risk: Possibility that revenues of the insurer will not be sufficient to cover expenditures incurred in the delivery of contractual services.

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S

SEHI: See Small Employer Health Insurance.

Self-funded: See Administrative Services Only.

Self-insured: Management in which health services are delivered by providers, but the cost of these services is covered by the member's employer, not the insurance firm.

SHOP: Small Business Health Option Program. The exchange (online marketplace) where small employers can purchase health insurance for their employees beginning in 2014 as part of the ACA. Using SHOP is optional; employers may continue to buy health plans directly from an insurance carrier.

Skilled nursing care: Please see ACA Uniform Glossary.

Skilled Nursing Facility (SNF): A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation and/or medical care that is of a lesser intensity than that received in a hospital.

Small Employer Health Insurance: A small employer is one that employs an average of 2 to 50 employees during the preceding calendar year. Special insurance rules apply to groups of this size.

SNF: See Skilled Nursing Facility

Solo practice: Individual practice of medicine by a physician who does not practice in a group or share personnel, facilities, or equipment with other physicians.

Special Enrollment: Under HIPAA, Link to term special mid-year enrollment opportunities that group health plans must offer to certain unenrolled employees and dependents who experience a mid-year loss of other coverage and when there is a mid-year adoption or placement for adoption, birth, or marriage.

Specialist: Please see ACA Uniform Glossary.

Stop-Loss: Stop-loss is risk protection from withhold losses resulting from claims greater than a specific dollar amount per member per year.

Subrogation: When healthcare costs of enrollees are the responsibility of an entity other than the insurer, such as workers' compensation, third party negligence liability, or automobile medical coverage.

Subscriber: The person who is responsible for payment to PacificSource, or whose employment or other status, except for family dependency, is the basis for eligibility for membership in PacificSource.

Summary Plan Description (SPD): Under ERISA, a summary of an employee benefit plan's terms that must be furnished, subject to very limited exceptions, to covered participants and certain other individuals.

Supplemental Medicare: Plan that covers some copays, deductibles, and other services not covered under traditional Medicare.

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T

Tertiary care: Healthcare services which are not available through a community hospital setting. This may include complex cancer procedures, transplants, and neonatal intensive care.

Third party administrator (TPA): An independent person or corporate entity that administers group benefits, claims, and administration for a self-insured group or insurance company. A TPA does not underwrite risk.

Third party liability: The circumstance under which a company other than PacificSource is responsible for paying a member's claim.

Third party payment: Payment for healthcare by a party other than the member.

TPA: See Third Party Administrator.

Trend rate: The rate at which medical costs are changing due to such factors as prices charged by medical care providers, changes in the frequency and pattern of utilizing various medical services, cost shifting, and use of expensive medical technology.

Triage: The classification of sick or injured persons, according to severity, in order to direct care and ensure the efficient use of medical and nursing staff and facilities.

TRICARE/CHAMPUS: The U.S. Military's healthcare program. See CHAMPUS.

Triggering Event: One of several specific events listed in the COBRA Link to term statute that will result in a qualifying event if it also causes a loss of coverage under a group health plan.

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U

Usual, customary, and reasonable (UCR): Please see ACA Uniform Glossary.

Underwriting: Process by which PacificSource determines the basis on which it will accept an application for insurance.

Urgent care: Please see ACA Uniform Glossary.

USERRA: The federal Uniformed Services Employment and Reemployment Rights Act, which requires employers to provide certain re-employment and benefit rights to employees who take a leave of absence for service in the uniformed services.

Utilization: The extent to which the members of a covered group uses the services or procedures of a particular benefit plan.

Utilization review: A set of formal techniques used by an insurer or delegated by the insurer designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy, or efficiency of healthcare services, procedures, or settings.

Utilization management program: The programs and processes established by PacificSource and carried out by PacificSource with the cooperation of contracted providers to authorize and monitor the utilization of covered services provided to members.

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V

Value Drug List (VDL): A list of brand name prescription drugs that are available for a plan's Tier 2—Preferred copayment. This list is subject to change as new drugs constantly enter the market.

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W

Waiting Period: A period that must pass before an employee or dependent is eligible to enroll under the terms of a group health plan.

Wellness Program: A program of health promotion and/or disease prevention.

WHCRA or Women's Health and Cancer Rights Act: A federal law that requires group health plans that provide mastectomy benefits to provide coverage for reconstructive surgery and certain other related benefits.

Workers' Compensation: A state-governed system designed to address work-related injuries. Under the system, employers assume the cost of medical treatment and wage losses arising from a worker's job-related injury or disease, regardless of who is at fault. In return, employees give up the right to sue employers, even if injuries stem from employers' negligence.

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YTD: Year-To-Date

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Last updated 7/8/2014