Health Maintenance Organization: An organization that provides a wide range of comprehensive health care services through a designated group or network of doctors, hospitals, labs and other providers. To receive benefits, you must see the doctor you select as your primary care physician first, for care or a referral, except in the case of an emergency. Your choice of doctors is restricted to those in the network. The Primary Care Physician is paid a certain “fixed” fee for each member each month after enrollment. This fee is called a “capitation fee.” In California, women have the option of self-referral to their OB-GYN. Typically the OB-GYN needs to be within the network of physicians that her primary is in (i.e. Sharp Rees-Stealy).
E.O.B.
Explanation of Benefits (E.O.B): The statement sent to a patient (by the insurance company) following a procedure. This statement typically breaks down the cost of the procedure, the co-pay amount from the patient, the insurance paid amount and “negotiated rate” discounts.
Emergency Services
Services provided that are medically required on an immediate basis for an illness or injury, in order to prevent loss of life, permanent impairment of bodily functions or other severe medical consequences.
Drugs, Non-Formulary
Prescription Drugs that are not on a particular plan’s formulary list. Plans vary on coverage of these drugs. Your Physician is provided a book of accepted medications by each carrier.
Drugs, Generic
A generic drug is produced and sold under the chemical name. Generic drugs are considered therapeutically equivalent to the brand name drugs by the Food and Drug Administration. Generic drugs, when available, are usually your best value. Typically lower co-payments are needed for generic drugs compared to brand name drugs. A generic drug can be manufactured after the patent has expired on a brand name pharmacy.
Drugs, Formulary
Prescription drugs which the medical literature indicates are clinically effective, safe and of reasonable cost. The goal of a formulary list of prescription drugs, as established for a plan, is to identify and promote prescription drugs which are therapeutically appropriate and cost-effective.
Deductible
The dollar amount an insured individual must pay for covered expenses during a calendar year before the plan begins paying co-insurance benefits.
Covered Expenses
Charges for services which are medically necessary and eligible for payment under the plan. A covered expense can be no more than the maximum amount stated in the plan. Some tests or procedures require prior authorization from the insurance company. A good example of a test needing prior authorization is a MRI.
Co-Pay
The flat amount or percentage you pay for a covered service after you satisfy the annual deductible, if any. Please note many plans offer co-pays that are separate of the deductible. In other words, it may cost you $30 to visit the physician and an additional 30% of a service such as a blood test. Co-Pay plans were introduced to California plan designs about 15 years ago in response to consumer responses. Office visit co-pays are clearly spelled out in a plan design. Some insurance companies have re-designed their plans to include a percentage co-pay rather than a fixed amount.