Allowed Charges
This is the maximum fee allowed by the Plan for service. The carriers' contracted providers have agreed to accept the Plan's eligible charges for service. When a member goes to a participating provider, they are not required to pay any charges in excess of the eligible charges for covered services.
Ambulance
Ambulance is the transportation of a plan member for medical reasons. Most plans cover ground and air ambulance. See your plan outline of coverage for more details.
Calendar Year
January 1 through December 31 of the same year.
Chiropractic
Chiropractic refers to the health care treatment from a participating chiropractor. A chiropractor practices treatment for back and joints.
Coinsurance
Coinsurance is the percentage of provider's eligible charges payable by a member directly to a provider at the time of service. The coinsurance amount is usually stated as a percentage. For example, your coinsurance is 80%/20%, meaning the carrier pays 80 percent and the member pays 20 percent. Failure of a member to pay the amount specified in the member payment summary, or to make payment arrangements that are satisfactory to the provider, may result in the denial of non-emergency services and is grounds for termination of coverage for the member under the contract agreement.
Copay
A copay is a fixed dollar amount payable by a member to a provider at the time of service. The copay amount is stated in the schedule of benefits. Failure of a member to pay the amount specified in the member payment summary, or to make payment arrangements that are satisfactory to the provider, may result in the denial of non-emergency services and is grounds for termination of coverage for the member under the contract agreement.
Covered Services
Subject to all terms, conditions, limitations, exclusions, and requirements of the contract, covered services are those medically necessary basic health care services, supplies, and equipment for the treatment and diagnosis of conditions for which the Plan benefits apply. Covered services generally include emergency services, inpatient hospital services, physician services, outpatient medical services, and some limited out-of-area coverage for emergency and urgent care.
Durable Medical Equipment (DME)
Medically necessary equipment which is: (a) prescribed by a physician; (b) able to withstand repeated use; (c) primarily designated for medical purposes and not for convenience, contentment, personal comfort, or other non-therapeutic purposes; (d) required for activities of daily living; and (e) is generally not useful in the absence of an illness or injury.
Eligible Charges
This is the maximum fee allowed by the Plan for service. The carriers' contracted providers have agreed to accept the Plan's eligible charges for service. When a member goes to a participating provider, they are not required to pay any charges in excess of the eligible charges for covered services.
Eligible Dependent
A subscriber's lawful spouse and any child who meets the definition of eligible family dependent set forth in the contract.
Emergency Services or Emergency Care
Health care services that are provided for a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, that would lead you to believe that your condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in the following:
Placing your health, or if you are pregnant, the health of your unborn child in serious jeopardy;
Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part.
Exclusions & Limitations
Plan exclusions are procedures that are not covered under the plan. Limitations are procedures that may be covered under the plan if certain requirements have been met; such as waiting periods or prior authorization. Please read over and consider your plan exclusions and limitations before purchasing a plan. For specific information please call us at 1-866-446-1046.
Explanation of Benefits (EOB)
When claims are paid, the Plan sends the member an EOB, listing payments made by the Plan and any charges the member is responsible to pay directly to the provider or facility. The EOB is not a bill.
Home Health Care
Medical care and treatment rendered to a sick or injured member at the member's home by a nurse, under the general supervision of the member's physician, when such home health care providers work within an organization or company licensed by the state to provide such medical care and treatment.
Hospice
This is a provider that offers relief and supportive services to terminally ill patients and their families. This service may be offered in the form of physical, psychological, social, and spiritual care. These services are provided by an interdisciplinary team of professionals and volunteers who are available at home and in specialized inpatient settings.
HSA Eligible
This means that the plan is eligible for a health savings account. For more information on an HSA please call Chris Bowerbank at 866-446-1046 or click HERE.
Immunizations
This is a process that increases a person's ability to react to antigen and therefore improves ability to resist or overcome infection.
Infertility
Infertility refers to the treatment given to females, which will increase their chances of becoming pregnant. There are usually exclusions and limitations to certain treatments. Please see plan outline of coverage for more information or call Chris Bowerbank at 866-446-1046.
Inpatient Hospital Services
Admission to a health facility that provides board and room for the purpose of observation, care, diagnosis or treatment, with anticipation of staying at least 24 hours.
Lifetime Maximum Benefit Limit
The maximum accumulated payment that will be made by the Plan for covered services rendered to a member during the member's lifetime. The limit includes all amounts expended on behalf of the member under prior or subsequent contracts, affiliated, or subsidiary companies of the carrier.
Maternity
Maternity is health care relating to obstetrics, including prenatal care, and delivery.
Medical Deductible
The portion of eligible charges payable by a plan member each year directly to providers for covered services before the Plan provides benefits. This deductible may be for an individual member or a family. The deductible(s) are specified on the outline of coverage.
Medical Out-of-Pocket Maximum
The maximum dollar amount per calendar year of eligible medical charges payable by a plan member directly to providers as deductibles, copays, and coinsurance. The medical out-of-pocket maximum and charges that do not apply to the medical out-of-pocket maximum are specified on the outline of coverage. Except where noted otherwise on the outline of coverage, the Plan will pay 100 percent of eligible medical charges during the remainder of the calendar year once the medical out-of-pocket maximum is satisfied. Member payments for non-covered services or excess charges are not applied to the out-of-pocket maximum.
Mental Health
Mental health refers to psychiatric and/or psychological conditions. E.g. Depression, bi-polar disorder, anxiety, etc...
Nonparticipating Provider
Health care providers and health care facilities that are not under contract with the Plan. Except for emergencies, out-of-area urgent conditions, and other exceptions individually approved by the Plan, any covered services provided by a nonparticipating provider or facility are not covered or are covered at the standard benefit.
Office Visit
An office visit is considered medical care given at a doctor's office. Inpatient and Outpatient services are not considered an office visit. Many plans offer an office visit copay of $15 or $20. Some plans require that you meet your medical deductible first before paying a copay. Some exclusions and limitations apply. Check your plan outline of coverage for details.
Outpatient Hospital Services
Medical care provided at a health facility to members who are not confined to a hospital. Outpatient services may include diagnosis, observation, treatment and rehabilitation.
Pharmacy Benefit
The benefit paid by the insurance carrier. The plan member usually pays a copay or coinsurance for their prescription drugs. Most pharmacy benefits are categorized by 3 tiers: Generic/Formulary (name brand)/non-formulary (usually the newest most expensive drugs). Some plans require the member to meet a pharmacy deductible before the plan member pays a copay or coinsurance for the medication. See your plan outline of coverage for details.
Pharmacy Deductible
The fixed, out-of-pocket amount payable each calendar year directly to providers at the time of service by a member, which must be paid toward the purchase of prescription drugs before prescription drug benefits are payable by the Plan. The pharmacy deductible is specified in the plan outline of coverage. Failure of a member to pay the pharmacy deductible amount specified in the outline of coverage, or to make payment arrangements that are satisfactory to the provider, is grounds for termination of coverage for the member under the contract.
Pharmacy Out-of-Pocket Maximum
The maximum dollar amount per calendar year of eligible prescription drug charges payable by a plan member directly to providers as deductibles, copays, and coinsurance. The pharmacy out-of-pocket maximum and charges that do not apply to the medical out-of-pocket maximum are specified on the outline of coverage. Except where noted otherwise on the outline of coverage, the Plan will pay 100 percent of eligible pharmacy charges during the remainder of the calendar year once the pharmacy out-of-pocket maximum is satisfied. Member payments for non-covered prescriptions or excess charges are not applied to the out-of-pocket maximum.
Physical Therapy
This is treatment regarding the recovery process from an accident or illness.
Premiums
The monetary amount an employer pays the Plan as consideration for the Plan providing covered services to members under the contract. This may also be referred to as the prepayment fee. In the case of personal plans, the member pays the premium(s).
Preventive Care
This is care to detect health problems before they become serious. Preventive care includes, but is not limited to, routine exams, hearing and vision exams, immunizations, mammograms, Pap smears, cholesterol tests, and blood pressure checks.
Pre-Existing Condition (PEC) Waiting Period
The twelve (12) month period during which treatment or services provided for a pre-existing condition are not covered or coverage is limited. The PEC waiting period begins on a member's enrollment date of coverage with the Plan. If the newly covered member is a late enrollee, the PEC waiting period may be extended to eighteen (18) months.
Any PEC waiting period or portion thereof which was satisfied by previous periods of creditable health care coverage, not separated by more than a sixty-three (63) day break in coverage, will be applied toward satisfying all or part of the PEC waiting period under the contract.
Skilled Nursing Facility
This is a qualified, licensed facility designated by Altius that has the staff and equipment to provide skilled nursing care, as well as other related health services.
Supplemental Accident Benefit
This is a first dollar benefit that will be paid out by the insurance carrier upon emergency room treatment of an accident. For more information, call Chris Bowerbank at 866-446-1046.
Urgent Condition/Care
An urgent condition is an acute health condition with a sudden, unexpected onset, which is not life-threatening but which poses a danger to a person's health if not attended to by a physician within 24 hours for example: upper or lower respiratory conditions, sore throats, sprains/strains, and headaches. Types of conditions that would never be considered urgent care include, but are not limited to: therapy (physical, occupational, speech, chronic pain management), ongoing treatment, preventive care, elective care, extended follow-up care, chemotherapy, radiation, and dialysis. Services are provided for urgent conditions through a member's doctor or a participating specialist, IHC InstaCare (if with SelectHealth), or participating UrgentCare. Outside the Plan's service area, urgent care may be obtained from any qualified health care provider or facility.
