A
Affordable Care Act
A 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.
Annual Deductible
The amount you are required to pay annually before reimbursement by your health plan.
B
Benefits
The health care items or services covered by IEHP, sometimes referred to as a "benefits package."
C
Claim
An itemized bill from a health care provider for health services provided to a member.
Claim Form
A form you or your doctor fill out and submit to IEHP for payment.
Contracting Hospital
A hospital that has contracted with a IEHP to provide hospital services to our members.
Copay
The set dollar amount you pay for a covered health care service at the time you get care or when you pick up a prescription drug.
Covered Person
The person enrolled in IEHP and/or any enrolled eligible family members.
Covered Service
A service that is covered according to IEHP.
D
Deductible
The amount you pay for most covered services before your health plan starts to pay. When you go to a provider who is in our network, before you meet the deductible, you may pay a discounted amount that has been negotiated with the provider. The deductible resets at the beginning of the calendar year or when you enroll in a new plan.
Dependent
An eligible person, other than the member (generally a spouse or child), who has health care benefits under an IEHP.
E
Effective Date of Coverage
The date your coverage begins. The effective date can also represent the date a change in your coverage takes effect.
Emergency Medical Care
Services provided for the first treatment of an acute medical condition, usually in a hospital setting.
Exclusions
Specific medical conditions or circumstances that are not covered under IEHP.
Explanation of Benefits (EOB)
An EOB is created after a claim payment has been processed. It explains the actions taken on a claim, such as the amount that will be paid, the benefit available, discounts and the claims appeal process.
F
Family Coverage
Health care coverage for an IEHP member and their spouse and any eligible dependents.
G
Generic Drug
A prescription drug that is the generic equivalent of a brand name drug.
Grievance
An oral or written expression of dissatisfaction regarding IEHP staff, policies or processes, our contracted providers’ staff, processes or actions, or any other aspect of health care delivery through IEHP.
Guaranteed Issue
A requirement under the Affordable Care Act that health insurers must permit you to enroll in some form of insurance coverage regardless of health status, age, gender or other factors.
H
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that ensures the protection of sensitive patient health information from being disclosed without the patient’s consent or knowledge.
I
Individual Health Plan
Health care coverage for an individual with no covered dependents. Also known as individual coverage.
In-Network
Services provided by a physician or other health care provider with a contractual agreement with IEHP.
Inpatient Services
Services provided when a member is registered as a bed patient in a health care facility, such as a hospital.
Insured Person
Often referred to as a member/subscriber.
J
K
L
M
Managed Care
A coordinated approach to providing quality health care at a lower cost; usually associated with HMOs.
Medicaid
A joint federal- and state-funded program that provides health care coverage for low-income children and families, and for certain ages and disabled individuals.
Medi-Cal
No-cost health care coverage for low-income working families with children, low- income seniors, and people with disabilities.
Medical Group
A group of doctors and other health professionals who have a shared medical practice and contract with a health plan to deliver health care services to plan members.
Medicare
The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65.
Member
Any recipient enrolled in IEHP’s plan.
N
Network
The group of doctors, hospitals and other health care professionals that contract with IEHP to deliver medical services to our members.
Non-Contracting Hospital
A hospital that has not contracted with a particular health plan to provide hospital services to members in that plan.
O
Out of Network (OON)
Services are considered out of network when you use a doctor or other provider that does not have a contract with IEHP. Out of network services may not be covered or may be covered at a lower level. You may be responsible for all or part of an out of network provider's bill.
Outpatient Services
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.
P
Practitioner
A physician, non-physician medical practitioner, or other Provider of Service.
Prescription Drugs
Prescription drugs must be ordered by a doctor and obtained at a pharmacy. They are reviewed and approved through a formal process set by the U.S. Food and Drug Administration (FDA).
Prescription Drug List
A list of commonly prescribed drugs (also known as a drug formulary). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.
Preventive Care Services
Health care provided for prevention and early detection of disease, illness, injury or other health condition and, in the case of a full service plan includes but is not limited to all of the basic health care services.
Primary Care Physician (PCP)
The physician you choose to be your primary source for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists and serves as tyour “gatekeeper” for managed care plans. The PCP is a general practitioner, internist, pediatrician, family practitioner, or obstetrician/gynecologist (OB/GYN).
Prior Authorization
The process by which a plan member or their doctor gets approval before the member undergoes a course of care, such as a hospital admission or a complex diagnostic test. Also called preauthorization.
Provider
A licensed health care facility, program, agency, doctor or health professional that delivers health care services.
Q
Qualified Health Plan
A health plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (deductibles, copays and out-of-pocket amounts) and meets other requirements.
R
Referral
A written authorization from a member's primary care physician (PCP) to receive care from a different contracted doctor, specialist or facility.
S
Specialist
A health care professional whose practice is focused on a certain branch of medicine, including specific procedures, age categories of patients, specific body systems or certain types of diseases.
T
U
Urgent Care
Health care for a condition which requires prompt attention.
V
W
X
Y
Z