It is between a customer (an individual or group) and an insurance plan. External link You are leaving this website/app (site). In most HMO plans, members choose a primary care physician (PCP). What is the difference between a subscriber and a member? Generic drugs often have lower copays. It is caused when the jaw joints and muscles controlling them don't work together correctly. This is for workers who will receive a pension when they retire. You pay this amount every month. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. It is the amount paid each week. Such events could cause loss of sight, speech or hearing. This is for employees who are disabled and covered under a long-term disability plan. The PCP gives routine care and refers members to network doctors if special care is needed. Or they can be treated and leave the same day. This is a list of prescription drugs the health plan covers. This is the way health plans decide how much they will pay for certain expenses. Sometimes it is called a PDP. An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members. Health plans that are considered MEC include individual and family plans bought through the Health Insurance Marketplace,qualified health plansbought directly through an insurance company such as Blue Cross and Blue Shield of Illinois, job-based coverage, Medicare, Medicaid, and certain other coverage. Usually, the network provides services at a special rate. This is a treatment used to fight cancer. This form is used to report a person's income to the Internal Revenue Service (IRS). This is an artificial body part. In these plans, people might have lower copays for drugs on the preferred drug list. The group advises a health plan company on safe and effective drug use. For long-term disability, it is the last day the person worked part of a day. This means a condition is dangerous. Identification cards issued by a pharmacy benefit management plan (PBM) to plan members. Medical care rendered by a specialist (e.g. A large group may be defined as more than 250, 500, 1,000, or some other number of members, depending on the managed care organization. Members can get care from a provider who is not a PCP. Example: A disability plan pays 60% of your salary. They stay in it for two or four weeks. It shows the member's assigned plan number and plan contact information. See specialty health maintenance organization. The most you have to pay for covered services in a plan year other. The site may also contain non-Medicare related information. It is used to limit the effects of disease. This is called an MA-PD. This is part of the original Medicare plan. Has a civilian no rights to a telephone as a. In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage. These drugs help treat chronic conditions. The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization and hospice care. A health care professional whose practice is limited to a certain branch of medicine, including specific procedures, age categories of patients, specific body systems or certain types of diseases. The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Also known as group universal life. The limit can be yearly or a dollar amount. It's not the same asCOBRA because its only for companies with less than 20 workers. It is used to be sure doctors and hospitals meet certain standards. Some procedures can be done in a hospital, surgery center or doctor's office. The data is based on what doctors charge for the health care service. And it usually cannot be renewed. This is how long a person is certified as disabled. This is a group of doctors or other health care providers. They might pay more for care. An open formulary provides a greater choice of covered drugs. The employee does not pay for the coverage. These are tests that a health care professional orders. The tests are sometimes called screenings. This includes terms that decide who can get coverage. It identifies the member's Blue Cross Blue Shield company or national account in order to properly route the claim. The process by which a plan member or their doctor gets approval from their health plan before the member undergoes a course of care, such as a hospital admission or a complex diagnostic test. It means an insurer can keep up life insurance coverage for a disabled employee. Services include help with bathing, dressing and eating. How much a plan covers may vary from drug to drug. An application for payment of benefits under a health plan. There are many different types of these plans. Blue Distinction. This is a request to be paid by a health plan for health services given. These centers can treat urgent, but non-life-threatening medical issues. With a Health Savings Account, or HSA, you set aside money before taxes. These are plan documents. Buying them through a mail-order pharmacy can save money. This is a type of dental specialist. It can also be the total number of services you can receive. It is a customer (an individual or group) who buys an insurance plan from an insurer. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. They decide this by using medical standards or research that states what care is most effective. The health care providers in the network sign a contract with a health plan to provide services. These are medical costs that a member must pay. This is a federal law. If a member needs a drug on this list, the doctor must ask the plan to cover it as an exception. One option is Adobe Reader which has a built-in reader. A time outside the open enrollment period during which you can sign up for health insurance. This is a plan offered by a plan sponsor to an employee group or other group. This is an optional benefit. If the period is five years, people must list all conditions they had or were treated for in the last five years. Most health plans have specific guidelines to define emergency medical care. The requirements vary. There are three types of these plans. Also known as Medicare prescription drug plan or Medicare Part D. This is an optional Medicare plan. It gives Americans a check each month based on the years they have worked and the money they have earned during their life. The amount you pay for most covered services before your health plan starts to pay. These types of conditions are not always easy to recognize. It applies to workers who need to take time off from work for: This is a list of prescription drugs the health plan covers. This lets a person carry forward or "roll over" any balance in a health fund. Or call Member Services at the phone number listed on your Aetna ID card. They contract with one or more health plans to provide services. The website lets members log daily activities and track progress over time. It comes on suddenly. Out-of-network services may not be covered or may be covered at a lower level. New employees can enroll when they first start. Balances roll over year to year, per employer rules. It lists how much of a benefit each worker gets. A coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code for the entire procedure. It is separate from a Medicare health plan. This is a joint that connects the jaw to the skull. Or pharmacies, hospitals and labs. For shortterm disability, it is the last day a person worked half a day or more. It is something that needs immediate medical care. It depends on the policy. These funds can help pay for health care. In case of a conflict between your plan documents and this information, the plan documents will govern. Subscribers receive subject-specific emails for urgent announcements and other updates shortly after they post to the Medi-Cal website. This law protects the rights of people with disabilities. It also lets members build up a fund that helps them save on taxes. There is a period in between when they are back at work. People may pay less when they visit this type of provider. This is the part of a bill that is eligible to be paid under your health plan. Also known as Centers for Medicare & Medicaid Services. In most plans, you pay this after you meet your deductible limit. A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons. Broadband technology will change all the rules, Boss tells ad staff: you really ought to subscribe at home; controversial New Haven Register memo is revealed by competing Hartford Courant, Valoe's board resolves on subscription of new shares, ADIB rights to start trading on ADX on August 16, Facebook brings follow option with 'Subscribe' button. Beginning in 2014, most insurance plans you can choose from whether you buy on the Health Insurance Marketplace or go directly to the insurance company of your choice will include many benefits that are meant to make sure basic health concerns are covered. This also is called medically necessary, medically necessary services or medical necessity. Some procedures can be done in a hospital, surgery center or doctor's office. We receive the data from Fair Health, an independent organization. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. The review and possible authorization of proposed treatment plans for a patient before the treatment is implemented. Members can go outside the group if the group can't handle their medical needs. It applies to treatment for disabilities due to alcohol or drug abuse. This is the total dollar amount of benefits you can receive. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. This can be part of a life insurance policy. Most PDF readers are a free download. It means a person must try certain drugs before the plan will pay for a particular brand-name drug. Health insurance is full of terms you may not know. This is a plan offered by a plan sponsor to an employee group or other group. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. This is a doctor who is part of a health plan's network. Register and log in today. And patients in remote places can get help from doctors and specialists who are far away. Employee Retirement Income Security Act of 1974 (ERISA). You get this after you receive an opinion from the first doctor you went to see. PCPs give referrals for other care. A comprehensive law passed in 2010, the Affordable Care Act was aimed at reforming America's health care system to improve access and affordability for more Americans. People sometimes need to prove they have had this so they can be fully covered by a new plan. And those who get married or have a baby can make changes in their coverage when this change in their life occurs. This federal act requires group health plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. In some health plans, a person must choose a PCP to coordinate care. It runs the Medicare program. This is a process used by some health plans. The money is often used to pay for funeral costs or other related costs. Or each time can happen because of a related condition. It lists doctors and health care professionals in the network. An individual or organization that offers care directly to the member. This is the amount of money an employee can get while out of work on disability. If it's a family health plan, the subscriber add people to it as dependents. It runs the Medicare program. The Health Insurance Marketplace, or Health Insurance Exchange, is a federal government website where you can shop, compare and buy plans offered by participating health insurance companies in your area. Also known as a skilled nursing facility. It is between a customer (an individual or group) and an insurance plan. Please be sure to add a 1 before your mobile number, ex: 19876543210, Learn more and download the Aetna Healthapp, Termination or reduction in the hours of a covered employee's employment for reasons other than gross misconduct, Divorce or legal separation from a covered employee, A covered employee becoming entitled to Medicare, A child's loss of dependent status (and therefore coverage) under the plan, Health care for members of the uniformed services, The Federal Employees' Health Benefit Program, A public health plan (any plan established by a state, the government of the United States, or any subdivision of a state or of the government of the United States, or a foreign country), Any health benefits plan under Section 5(e) of the Peace Corps Act, The State Children's Health Insurance Program (S-CHIP), Made for and mainly used to treat a disease or injury, Not for use in altering air quality or temperature, Mental health and substance use disorder services, including behavioral health treatment. They later do so during open enrollment. This can also be called: This term means types of health coverage a person has had. Examples are moving out of a plan service area, or being able to get Medicaid. Often the patient and the indirect care provider are in different physical locations. For plans that cover more than 1 person, individual out-of-pocket maximums counts toward the family out-of-pocket maximum. Then this cost might be shared between the person and the employer. To live free of worry, free of fear, because you have the strength of Blue Cross Blue Shield companies behind you. It is also called a preferred drug list. This is an account set up to help members pay for health care costs. The figure used to determine eligibility for lower costs in the health insurance marketplace, Medicaid and the Children's Health Insurance Program (CHIP). This is a condition in which high levels of protein are found in the urine. The plan pays a percentage of each covered health care service. This is an employee benefit. It is stored online and viewed on a computer. A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered. The integration of financing and delivery of healthcare within a system that seeks to manage the accessibility, cost and quality of that care. It can include drugs that are brand name and generic. Since several factors determine whether a discount will be given, Aetna is unable to guarantee any level of discount under this program. This is a law for employers with 50 or more workers. medical: [adjective] of, relating to, or concerned with physicians or the practice of medicine. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. The most you have to pay for covered services in a plan year. Medical Cost-Sharing Group. The third type is for those with a condition that is disabling. This health plan has to meet federal rules. They get this amount no matter how many patients they see. Buying them through a mail-order pharmacy can save money. This is when a person has an illness or injury. Please note that the effective date can also represent the date a change in your coverage takes effect. In them, employers give each worker a fixed amount of money. It is paid by both the insured person and the government. They are not covered under most prescription benefits plans. It helps prevent them from being treated unfairly on the job. It is the part of the Medicare plan where the member pays for prescription drugs. A form you or your doctor fill out and submit to your health plan for payment. This is a doctor who is trained to give care in a specific medical area. Some funds do both. This is a place that offers medical care. Also known as preventive care programs or wellness programs. Insurance brokers are also called agents. Also known as a medical-necessity review. Insurance brokers help a person or business buy an insurance plan. They work with other specialists and hospitals as needed. It can be paid to the insured person after an accidental injury. They think of themselves as married because of the time spent together. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). This is a health care provider who does not have a contract with a health plan. They are reviewed and approved through a formal process set by the U.S. Food and Drug Administration (FDA). CPT is a registered trademark of the American Medical Association. A member who sees a primary doctor in this group will be referred to specialists and hospitals in the same group. PII does not include publicly available information that is lawfully made available to the general public from federal, state or local government records or widely distributed media. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. The benefit company manages those payments. The insurance plan can be bought through a health insurance exchange. It may be written or sent by computer. This is a record of a person's health information. They must be reusable. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. These workers receive pay for medical costs and disability pay under this law. This is often used with workers who have not worked for a long time. Others have four tiers, three tiers or two tiers. When you need care and are on two different health plans, your insurers will coordinate your benefits to give you maximum coverage when you need it. Subscriber: The individual who signs and is responsible for a contract with a health insurance plan. For language services, please call the number on your member ID card and request an operator. They say what your plan does not cover. There is no overnight stay. They bill patients to make up the difference between the approved fee and the top amount allowed by Medicare. An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment. Some examples are walkers, wheelchairs or hospital beds. It can be paid to the insured person after an accidental injury. This is so members can put money into a health savings account or health reimbursement arrangement. Health plans, disability insurance and Medicare do not help much. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. A written or oral complaint submitted by or on behalf of a covered person regarding: a) availability, delivery or quality of health care services; b) claims payment, handling or reimbursement for health care services; or c) matters pertaining to the contractual relationship between a covered person and a health carrier. The direct care provider is in the same physical location as the member and offers care to patients from within the local Plan's service area. This is a part of a health plan. Employees may have an illness or injury. The fee determined by an MCO (managed care organization) to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. An agreement with a provider not to bill the subscriber for any difference between billed charges for covered services (excluding coinsurance) and the amount the provider has contractually agreed with a Blue Cross Blue Shield company as full payment for those services. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Accidental death and dismemberment (AD&D). Usually, the network provides services at a special rate. General medical care that is provided directly to a patient without referral from another physician. It can be offered as part of a Medicare Advantage plan. The third type is for those with a disabling condition. This is a type of health plan. The person gets to keep group insurance as an individual policy. These are services provided to support your health care. Prescription drugs must be ordered by a doctor and obtained at a pharmacy. If nothing in their life changed, they must wait for an enrollment period. People usually find the phone number for Member Services on their Aetna ID card. The MCO (managed care organization) committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation and changes in authorization procedures. In prescription drug plans, it is the amount you pay for covered drugs. The plan does not pay. The disease is caused by bacteria that stick to teeth and teeth roots. Catastrophic plans are an option to consider for young adults and people for whom coverage would otherwise be unaffordable. They are also called offsets or reductions. It includes such information contained in any form or medium (electronic, paper, oral, etc.). Maximum dollar amounts set by MCOs (managed care organizations) that limit the total amount the plan must pay for all healthcare services provided to a subscriber per year or in his/her lifetime. The person goes home after the procedure. Health Insurance Portability and Accountability Act (HIPAA). This is a type of health plan. It sets national standards for handling private health records. The plan category affects the total amount you'll spend on health benefits. It gives support and counseling to help people deal with stress, family issues and more. It is licensed. It is offered through a private company. The list has doctors, hospitals, dentists, pharmacists and more. This benefit can be paid in two ways. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Information that relates to an individual's past, present, or future physical or mental health or condition, or the past, present, or future payment for the provision of health care to an individual, including demographic information, received from or on behalf of a health care provider, health plan, clearinghouse, or employer, which either identifies the individual or could be reasonably used to identify the individual. This can help improve care. Long-term disability (LTD): Employees may have an illness or injury. The money goes into a fund the worker can use to pay for different health expenses. They contract with one or more health plans to provide services. One sits in front of each ear. Contract (also known as a benefit certificate or policy). It affects the gums and bones supporting the teeth. These are often newer drugs, treatments or tests. COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986). You can take your account with you if you leave your job. It can be an employer. This is an agency that makes state insurance laws. Two examples are hospitals and clinics. Brand-name drugs have higher copays. The Patient Protection and Affordable Care Act (commonly called the ACA) was signed into law in 2010 to address access, quality and cost in the healthcare industry. In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing.
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