Terms to Know

  • ACO (Accountable Care Organization): An organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.
  • Balance Billing: The excess charges over the amount covered by insurance, deductibles, co-insurance and co-payments. Providers in your plan have agreed to accept the amount paid by insurance, plus co-insurance and deductibles, as full payment. Balance billing is often prohibited.
  • Clinically Integrated Network:  A group of healthcare providers working together, using proven protocols and measures, to improve patient care, decrease cost and demonstrate value.
  • CMS: Centers for Medicare & Medicaid Services, a part of the Department of Health and Human Services.
  • Co-insurance: The percentage of the cost of health services that is paid by the employee. Co-insurance amounts vary from plan to plan.
  • Co-payment:  (“co-pay”)  The patient’s part of the bill paid at the time of service.  Typical co-payments range from $25-$50 for each visit to a physician, depending on the specialty.
  • Deductible: The amount of money an individual must pay for health services before the insurance company will pay anything towards health care charges. A deductible will be different for single and family coverage.  Deductibles are usually set for a period of time, usually a year.
  • Drug Formulary: A list of preferred, clinically effective prescription drugs that are covered by insurance. Often this list consists of name brands and their generic equivalent. Typically, the generic will cost less than the name brand. Covered brand name drugs listed on the formulary have a lower co-pay than covered brand drugs that are not included. Consult your doctor or pharmacist about generic alternatives.
  • Explanation of Benefits (EOB): Statement mailed to you explaining how and why a claim was or was not paid. You should save these documents for future reference should there be an issue with claims payment.
  • MSSP (Medicare Shared Savings Program):  A CMS sponsored program committed to achieving better health for individuals, better population health, and lowering growth of expenditures.
  • Network: The combination of individual and group practitioners, hospitals, clinics, and facilities who have agreed to see patients, provide care at negotiated rates, and adhere to the policies and procedures of the insurance plan.
  • Out-of-Area Coverage: Benefits for health care provided outside the normal service area of the health plan. Such benefits are usually paid for by the plan in emergency circumstances when you’re away from home. Benefits are often lower for out-of-area coverage.
  • Out-of-Pocket Expenses:  The amount of money an individual has to pay for health services.  This includes deductibles, co-insurance, co-payments, and items and services not covered by insurance (e.g., glasses, contacts, etc.).  This would also include costs which exceed the limits of the coverage.
  • Out-of-Pocket Limit/Maximum: The amount an individual pay before insurance will pay 100% benefits up to the coverage maximum, if any. Until this is met, the employee will pay co-insurance.
  • Pre-admission Certification (PAC): Also called a “pre-cert”, is review and approval from your insurance company for procedures prior to having them.  Insurance companies will determine the  need and appropriateness of physician orders prior to your admission to a hospital or ambulatory setting. Under health plans where PAC is required, pre-admission certification is a requirement for reimbursement.
  • Premium: The dollar amount paid for insurance coverage for a specified time.
  • Provider: a person or facility that provides healthcare services – doctors, nurse practitioners, hospitals, midwives, surgical centers, and hospital-based doctors. Always check that your provider is a participating provider for your insurance PRIOR to receiving health services from them.
  • Triple-Aim:  The goal of population health management and value-based programs.                1. Improved quality 2. Better outcomes 3. Lower cost.
  • Value-based Care:  Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare These programs are part of our larger quality strategy to reform how health care is delivered and paid for.