Health Dictionary

Ancillary Care,
Ancillary Provider

Additional healthcare services performed, such as lab work and X-rays.

Autism Spectrum Disorders

Means any of the following pervasive developmental disorders as defined by the Diagnostic and Statistical Manual:

• Autistic disorder
• Asperger’s syndrome
• Pervasive developmental disorder not otherwise specified

The state of Michigan mandated coverage upon renewal after Oct. 15, 2012

Birthday Rule

Used when coordinating benefits between two benefit plans; a determination that the parent or guardian whose birthday falls earlier in the year has primary responsibility for a dependent’s insurance.

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.

Brand Name Drug

A prescription drug marketed under a specific brand name by the company that manufactures it and that meets FDA standards for safety, purity, strength and efficacy.

CAHPS

Consumer Assessment of Healthcare Providers and Systems. Comprehensive study of member satisfaction. Physicians Health Plan uses results to improve all areas of our business.

COB

Coordination of Benefits. A  provision that applies when a person is covered under more than one group healthcare program. It requires that payment of benefits will be coordinated by all programs to eliminate overinsurance or duplication of benefits.

COBRA

Consolidated Omnibus Budget Reconciliation Act. A federal law that requires employers to offer continued health insurance coverage to certain employees and their dependents whose group health insurance coverage has been terminated. It applies to employers with 20 or more eligible employees. It typically makes continued coverage available for up to 18 or 36 months. COBRA enrollees may be required to pay 100 percent of the premium, plus an additional 2 percent.

COC

Certificate of Coverage. The document detailing the plan health benefits for HMO/POS and PPO plans.

Coinsurance

The portion of covered healthcare costs for which the covered person is financially responsible. Coinsurance is often applied, according to a fixed percentage, after a deductible requirement is met.

Copay, Copayment

A cost-sharing arrangement in which a covered person pays a specified charge for a specified service such as an office visit, outpatient prescription drugs, urgent care, or emergency room. The covered person is responsible for payment at the time the healthcare is rendered. 

Deductible

A portion of the benefits, under a policy, that the employee and/or dependents may satisfy before any reimbursement occurs.

Disease Management

A program for coordinating preventive, diagnostic and therapeutic measures for members who are at risk for or have specific chronic illnesses or medical conditions (e.g., diabetes, asthma, etc.). 

DME

Durable Medical Equipment. Things such as wheelchairs, C-Pap machines, hospital beds and braces.

EOB

Explanation of Benefits. Members receive them and they illustrate how a claim was paid by PHP. 

ERISA

(Pronounced “er-rissa”) Employee Retirement Income Security Act of 1974. Federal law that regulates retirement and employee-welfare benefit programs maintained by employers and unions. 

EHB

Essential Health Benefits - those benefits (such as inpatient hospitalization, physician office visits, etc.) chosen by the state of Michigan (as mandated by the federal Patient Protection and Affordable Care Act) that all plans for individuals and small groups on and off the healthcare exchange, must contain. 

FCA

False Claims Act. The False Claims Act established a federal law addressing claims fraud involving federally funded programs (e.g., Medicare or Medicaid). 

FLSA 

The federal Fair Labor Standards Act, which was amended by the Affordable Care Act to incorporate certain healthcare reform provisions. 

FMLA 

Family and Medical Leave Act. A federal law allowing an employee to take unpaid leave due to a serious health condition that makes the employee unable to perform his or her job or to care for a sick family member or a new son or daughter (including by birth, adoption or foster care). 

Formulary 

The list of drugs chosen by a health plan that are eligible for coverage under the plan. Drugs outside the formulary may be covered with prior authorization. 

FSA 

Flexible Spending Account. This allows an employee to set aside a portion of earnings to pay for qualified expenses as established in the cafeteria plan, most commonly for medical expenses but often for dependent care or other expenses. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes, resulting in substantial payroll tax savings. 

Fully Insured Plan 

A health plan under which an insurer bears the financial responsibility for claim payments and paying for all incurred covered benefits and administration costs. 

Generic Drug 

A generic prescription drug is produced by one or more manufacturers once the brand-name company’s patent has run out. A generic equivalent may be produced when, as approved by the FDA, the drug has met the same safety, purity strength and efficacy standards as its brand-name counterpart. Generics have the same active ingredients as brand-name drugs yet may offer significant cost savings for members. 

GINA 

Genetic Information Nondiscrimination Act (2008). Prohibits health plans from denying eligibility based on genetic information. 

GlobalCare 

 The new network for out-of-area groups/members and a secondary network for discounts on non-network services. GlobalCare is a "network of networks," in every state and internationally. GlobalCare replaced UHC Options PPO. HMO or PPO network-level benefits at a GlobalCare network will occur in the following circumstances:

• When the group/member is assigned an out-of-area Class. A primary network assignment (from the family of GlobalCare networks) will occur. Our logo and the assigned network’s logo appear on the front of the members’ ID cards
• If Care Coordination specifically authorizes network coverage by a GlobalCare provider

Gynecology

Gynecology is a branch of medicine that treats the female reproduction system.

Hayes 

Hayes Technology is the company PHP has selected to provide current clinical research data about new treatments, procedures, technologies, applications of existing technologies and other aspects of care. Hayes Technology is a resource that will help PHP gather facts for making clinical determinations for experimental or unproven treatments for all our product lines. 

HDHP 

High-Deductible Health Plan. A medical plan with lower premiums and higher deductibles than a traditional health plan. A “qualified” HDHP allows the participant to open a Health Savings Account (HSA) or an employer to open a Health Reimbursement Account (HRA), both of which are tax-favored accounts that allow the individual to use the accumulated savings to pay for eligible medical services that are not covered (e.g., applied to the deductible) by medical insurance. The Internal Revenue Service annually adjusts the minimum deductible/maximum out-of-pocket cost that must be complied with in order for a plan to be considered a “qualified” HDHP. 

HEDIS

(Pronounced “hee-dis”) Healthcare Effectiveness Data and Information Set. A core set of performance measures managed by the National Committee for Quality Assurance to assist employers and other health purchasers in evaluating health plan performance. It also is used by the Centers for Medicare & Medicaid Services to monitor quality of care given by managed care organizations. 

HIPAA 

(pronounced “hip-ah”) Health Insurance Portability and Accountability Act of 1996. Established a federal law intended to improve the availability and continuity of health insurance coverage that, among other things, places limits on exclusions for pre-existing medical conditions; permits certain individuals to enroll for available group healthcare coverage when they lose other health coverage or have a new dependent; prohibits discrimination in group enrollment based on health status; provides privacy standards relating to individuals’ personally identifiable claim-related information; guarantees the availability of health coverage to small employers and the renewability of health insurance coverage in the small and large group markets; requires availability of nongroup coverage for certain individuals whose group coverage is terminated; provides security standards relating to individuals’ claim-related information; establishes standards for electronic transmissions; and issues National Provider Identification (NPI) numbers to providers. 

HMO 

Health Maintenance Organization. An organization that provides comprehensive healthcare to voluntarily enrolled individuals and families in a particular geographic area by member physicians and that is financed by fixed periodic payments determined in advance. 

HMO/POS

An HMO plan that has network and non-network benefits (referred to as Plus benefits). 

HRA 

Health Reimbursement Arrangement. All contributions must be from the employer only with no employee contributions. There is no limit on the amount of money an employer can contribute. Qualified medical expenses include health insurance premiums, long-term care and amounts not covered under another health plan. 

HRA 

Health Risk Assessment. A health questionnaire used to provide individuals with an evaluation of their health risks and quality of life. 

HSA 

Health Savings Account. Tax-advantaged accounts to pay for qualified medical expenses when an individual is covered by a qualified high-deductible health plan. An eligible individual works with a trustee, which can be a bank or an insurance company, for example. Both the individual and his or her employer can contribute to a HSA. 

Integrated Healthcare Systems 

Healthcare financing and delivery organizations created to provide a “continuum of care,” ensuring that patients get the right care at the right time from the right provider. This continuum of care from PCP to specialist and ancillary provider under one corporate roof guarantees that patients get cared for appropriately, thus saving money and increasing quality of care. 

MCO

Managed Care Organization. The sector of health insurance in which healthcare providers are not independent businesses run by, for example, the private practitioner but by administrative firms that manage the allocation of healthcare benefits. In contrast to conventional indemnity insurers, which do not govern the provision of medical services and simply pay for them, managed care firms have a significant say in how services are administered so that they may better control healthcare costs. HMOs and PPOs are examples of MCOs. 

Marketplace

A web-based portal to be used by individuals and small groups to purchase health plans offered by many health insurers.  

MLR 

Medical Loss Ratio. Refers to the claims costs and amounts expended on healthcare quality improvement as a percentage of total premiums (excluding taxes, fees and certain adjustments). 

MRD 

Member Reference Desk. PHP’s web-based repository of all materials that members can access through our website. Members may review and/or request copies of their COC, any amendments, privacy notices, SBC, etc. 

MyPHP 

 A web-based program providing members, providers, producers and employer groups access to information. Members may view claims information, update demographics and gain access to the Personal Health Manager. Groups may use MyPHP for enrollment; providers can check claim status and enter authorization requests; and producers are able to perform similar tasks as group administrators. Group administrators and providers have assigned passwords for MyPHP access, which are mailed to them. Members can self-register online. 

OOP 

Out of Pocket. The portion of payments for covered health services required to be paid by the enrollee, including copayments, coinsurance and deductibles. The OOP maximum is the maximum amount of copayments, coinsurance and deductibles that the enrollee will have to pay each calendar year. Once the out-of-pocket maximum has been met, the plan generally will pay 100 percent of covered medical expenses. 

Open Access 

PHP amended its plans several years ago to incorporate this concept of allowing members to see network providers, usually specialists, without referral from the PCP. These types of arrangements are most often found in IPA-model HMOs (i.e., PHP). 

OTC 

Over the Counter. A drug product that does not require a prescription under federal or state law. 

PCP 

Primary Care Physician (also referred to as primary care provider and primary physician). HMO plans require each member to have one. It’s usually a family practitioner but can be an internist, OB/GYN or pediatrician. 

PDL 

Preferred Drug List. A published list of prescription drugs that PHP covers under its outpatient prescription drugs plans.

PHI 

Protected Health Information. As defined in the Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations, PHI is any information about health status, provision of healthcare or payment for healthcare that can be linked to an individual. 

PPACA 

Patient Protection and Affordable Care Act of 2010; signed into law March 23, 2010 as part of healthcare reform. 

PPO 

Preferred Provider Organization. Similar to an HMO but not subject to some of the state and federal mandates for coverage and not as tightly managed and usually not as rich in benefits. A PPO is a health plan that gives a network option at lower out-of-pocket costs for the member and a non-network option at a higher cost share for the member. 

Pre-Existing Condition 

Any medical condition that has been diagnosed or treated within a specified period before the member’s effective date of coverage under the group or individual contract. 

QHP 

Qualified Health Plan. An federally-certified health plan that provides an essential health benefits package and is offered by a licensed health insurer. 

QMCSO 

Qualified Medical Child Support Order. From a court when there’s a divorce, it mandates how dependent children will receive health coverage. 

R&C 

Reasonable & Customary. The maximum amount PHP will consider in determining benefits, usually based on the most common charge for a given service in a given geographic area. R&C guidelines typically apply only to non-network expenses. 

Rx 

Written abbreviation for prescription. 

SBC 

Summary of Benefits and Coverage. A standardized summary of the benefits and coverage under a health plan that must be distributed to plan participants and beneficiaries. 

Self-Funded or Self-Insured 

A healthcare program in which employers fund benefit plans from their own resources without purchasing insurance. Self-funded plans may be self-administered, or the employer may contract with an outside third-party administrator (TPA) for an administrative services only (ASO) arrangement. Employers that self-fund can limit their liability via stop-loss insurance on an aggregate and/or individual claim basis. These types of plans fall under our TPA business entity, PHP Service Company. 

Service Area 

If covered services are obtained in this designated geographic area, benefits are paid at the network-benefit level. 

SHOP 

Small Business Health Options Program. A program that each exchange created under the Patient Protection and Affordable Care Act must create to assist eligible small employers in enrolling their employees in qualified health plans offered in the small group market. 

Subscriber 

The policyholder.

TPA 

Third-Party Administrator. Type of company that administers self-funded health plans. Our TPA entity is named PHP Service Company. 

URAC

An independent, nonprofit accreditation entity founded as a third-party healthcare quality validator.

WHCRA

(Pronounced “wick-rah”) Women’s Health and Cancer Rights Act. Under WHCRA, group health plans, insurance companies, and health maintenance organizations offering mastectomy coverage also must provide coverage for certain services relating to the mastectomy. This required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema. 

One phase of the Patient Protection and Affordable Care Act, which PHP implemented for all non-grandfathered plans on Aug. 1, 2012, which mandates services for women covered with no cost share, such as select contraceptives, surgical sterilization for women, more breast-feeding services and a breast pump.