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Glossary

A

Affordable Care Act

A federal law that requires most U.S. citizens and residents to have health insurance. The law also created health insurance marketplaces (or exchanges). In Connecticut, the exchange is called Access Health CT, where you can buy health insurance and possibly receive help paying for it, depending on your income.

Ambulatory services

Health services that do not require you to stay overnight in a hospital. You might receive these services in a hospital setting or at a free-standing facility, such as a walk-in clinic.

C

Care manager

A registered nurse (RN) or social worker at ConnectiCare who works with you and your doctor. This person helps coordinate your care and can educate you about your health condition.

Claim

A request to have health insurance pay for health care services. The request can come from you, your doctor, or another health care provider.

Claim summary

Explains the services you received, how much the doctor (or other health care provider) billed your health insurance, how much health insurance paid, and how much, if any, that you are responsible for paying.

COBRA

A federal law that gives you the right to continue  group health insurance coverage for a certain period of time if an employer terminates your job.

Coinsurance

A sharing of health care costs in which you and your insurance company each pay a percentage.

Contract or benefit plan year

The 12-month period that begins on the effective date of your health insurance plan.

Copayment or copay

A fixed amount that you pay for a certain health care service.

Cost share

The portion that are you responsible for paying toward your health care before your health insurance company starts to pay its share. There are different kinds of cost-shares, such as copayments, coinsurance and deductibles. See definitions for each.

D

Deductible

A specific dollar amount that you have to pay each year for your health care expenses before your insurance company starts to pay.

Dependent

A spouse, child, adopted child, or stepchild of the person who carries the health insurance coverage.

Drug tiers

Drug tiers indicate what you have to pay toward the cost of a prescription drug covered by your plan. Most of our prescription drug plans have four tiers, with drugs in tier one costing you the least and drugs in tier four  costing you the most.

F

Flexible spending account (FSA)

A special account you use to pay for certain medical and dental costs not covered by your health insurance plan. You contribute the money to your FSA, and all of it must be used by the end of the plan year or you will lose it. FSA money is not taxed, so when you pay for health care it's like getting a discount.

H

Health assessment

An online questionnaire that provides information about your current health. By answering a series of questions you receive a personal health score, a comparison with others of your age and gender, and recommendations for healthier living.

Health maintenance organization (HMO)

A type of health insurance plan that allows you to see any doctor or other health care provider who participates in the plan’s network.

Health reimbursement account (HRA)

A tax-free account that you can use to pay for qualified health care expenses. Your employer chooses to offer an HRA and sets the amount of funding in it. Your employer's healh benefit plan says what expenses you can may from your HRA. Those may include deductibles, copays, coinsurance, prescription drugs, doctor's visits, and hospital costs.

Health savings account (HSA)

A tax-free savings account that you may use with a high-deductible health plan (HDHP). The HSA allows you to set aside pre-tax money to pay for qualified health care expenses not covered by the health plan.

High-deductible health plan (HDHP)

A type of health insurance plan that requires you to pay a higher dollar amount for your care before the plan starts to pay. In exchange, you generally pay a lower monthly premium for the plan than you would for other types of plans. ConnectiCare offers HMO HDHP plans, which allow you to see any health care provider in our network; and POS HDHP plans, which allow you to see any health care provider, in- or out-of-network.

I

In-network

Doctors and other health care providers who participate in a health insurance plan's provider network and agree to accept the plan's negotiated payment for services. You typically pay less out of your pocket, if anything, when you use in-network providers.

Insurance exchange

Established by the Affordable Care Act in Connecticut and other states  to help people purchase health insurance. ConnectiCare offers a number of insurance plan options on Connecticut's public exchange, Access Health CT.

M

Managed care plan

A plan in which the health insurance company pays participating doctors negotiated rates for health care services. All of ConnectiCare's products are managed care plans.

Maximum allowable amount

The most that the health insurance plan will agree to pay an out-of-network doctor for a certain service. You may be responsible for paying any balance of the doctor's charges.

Medically necessary medical necessity

Health care services that a doctor provides to prevent, diagnose, or treat an illness, injury, or disease. The services must be clinically appropriate and reflect common medical practice.

Member

A person who is eligible to receive health care services under a health insurance plan.

O

Off-cycle plan change

When you request a change to your health insurance plan outside of the annual open enrollment period. A common reason is to add someone to your plan because of marriage or birth of child. These reasons are often called "qualifying life events.

Open enrollment

A certain period each year when you can enroll in a health insurance plan, add family members, or make other changes to your coverage. The choices you make will be in effect until open enrollment of the following year.

Out-of-network

Doctors and other health care providers who do not participate in a health insurance plan's provider network. You may be required to pay more out of your pocket when you use out-of-network providers.

Out-of-pocket maximum

Limits the total amount you have to pay each calendar year for health care expenses, including deductibles, copayments, and coinsurance. Monthly health insurance premiums do not count toward the out-of-pocket maximum.

Outpatient services

Health care services that do not require you to be admitted to the hospital.

P

Pharmacy benefit

The part of a health insurance plan that covers prescription drugs.

Plan type

The kind of coverage you have. ConnectiCare offers a number of plan types, including HMO, POS, PPO, HMO high-deductible, POS upfront deductible, and others. Your member ID card shows what plan type you have.

Point-of-service (POS) plan

A health insurance plan that gives the choice to see any health care provider, in- or out-of-network. Members pay less out-of-pocket, if anything, when they use in-network providers.

Premium

The monthly fee that is paid to the health insurance to provide your health coverage.

Prescription drug list

A list of prescription drugs that are covered by your health insurance plan. The category, or "tier," a drug is listed in determines how much you will have to pay toward it. Higher tiers mean you will have to spend more out of your pocket.

Preventive care

Care that your doctor provides to prevent illness or injury, as opposed to treating or diagnosing it. Examples include routine checkups, immunizations, and screenings, such as mammograms and colonoscopies. Your ConnectiCare health plan covers most preventive care services for free.

Primary care provider or PCP

A physician, physician’s assistant, or advanced practice registered nurse (APRN) who is your main contact for health care. Your PCP can do everything from writing prescriptions to referring you to a specialist when necessary. This is the person who knows the most about your health history and helps you navigate the health care system.

Prior authorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. This is also sometimes called preauthorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Prior authorization isn’t a promise your health insurance or plan will cover the cost.

Provider

A health care professional or facility that provide you with health care services. There are many types of providers, from hospitals and nursing homes to doctors and mental health counselors.

Q

Qualified medical expenses

Determined by the IRS, these are expenses that you can pay for using money from a health savings account (HSA), health reimbursement account (HRA), or flexible spending account.

Qualifying event

A change in your life that can make you eligible  to enroll in or change your health coverage outside of the open enrollment period. Examples include the birth of a child, marriage, divorce, or becoming eligible for Medicare. There are others, too.

S

Specialty drugs

Prescription drugs used to treat complex, chronic conditions like rheumatoid arthritis, multiple sclerosis, and cancer. Usually your doctor will need to ask ConnectiCare for prior authorization for these drugs.

Subscriber

An individual who enrolls in a health insurance plan and is eligible to receive covered health care services. Also known as the policyholder, this person may have dependents who are members of the plan.

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