Accountable Care Organizations (ACOs): A group of doctors, hospitals and other health care providers who take responsibility for and work together to provide coordinated medical care for a group of individuals.
Benefits: The health care services that are covered under a health plan.
BlueCard Network: The Blue Cross and Blue Shield Association (BCBSA) program that provides access to health care services from participating providers throughout the United States to members of any Blue Plan. Your level of coverage depends on your plan.'
Blue Priority HSA: A qualified high-deductible health plan that allows you to open a Health Savings Account (HSA) to pay for health care expenses tax-free.
Blue Priority HRA: A higher-deductible health plan in which your employer funds a Health Reimbursement Arrangement (HRA) to help you pay for health care expenses.
Claim: An itemized statement of health care services that a provider submits to Wellmark for payment when you receive care.
Coinsurance: A certain percentage of your medical expenses that you are responsible for paying. For example, if your coinsurance is 20%, you pay 20% of a hospital bill and your health plan pays the other 80%.
Coinsurance – Prescription: A certain percentage of your prescription drug expenses that you are responsible for paying. For example, if your coinsurance is 20%, you pay 20% of the cost of your prescription and your health plan pays the other 80% after you've met your deductible.
Contractholder: The person to whom the insurance policy has been issued. If you are an employee who has health coverage for you and your family through your employer, for example, you are considered the contractholder.
Consumer-Directed: A type of health plan that provides you with greater incentives to make wise health care choices. A high-deductible health plan paired with a health savings account (HSA) is an example of a consumer-directed plan. Premiums are usually lower than other health plans, but the higher deductible means you have greater responsibility for your health care costs.
Copayment: A fixed amount you pay for certain services (for example, $20 for a checkup at the doctor's office).
Copayment – Prescription: A fixed amount you pay for your prescriptions (for example, $10 for a Tier 1 prescription drug).
Cost Share: The amount you pay towards the cost of your care. Your cost share may be a copay (for example, $20 for a check up at the doctor's office) or coinsurance (for example, 20% of a hospital bill).
Cost Share – Prescription: The amount you pay toward the cost of your prescriptions. Your cost share may be a copay (for example, $10 for a Tier 1 prescription drug) or coinsurance (for example, 20% of the cost of your prescription).
Coverage: The health care services that you are covered for under a health plan.
Coverage Manual: An official document that provides you with details about covered and non-covered services under your health plan, as well as your out-of-pocket costs and information on how your health insurance plan is administered. If you have not received a coverage manual, you can request one by calling the customer service number on your ID card.
Deductible: Most health plans have a deductible. This deductible works just like car insurance. You must pay your deductible amount (for example, $250, $500, $1,000) before your insurance benefits kick in. Deductibles are usually based on a calendar year. Under some plans, the deductible is waived for specific services, like preventive care. Some plans have one deductible for health and another deductible for drugs.
Dependent Care Reimbursement: An employee benefit offered by many employers that allows you to pay daycare expenses pre-tax for eligible dependents. You can contribute up to $5,000 annually (or $2,500 if married and filing separately) to your dependent care reimbursement account.
Explanation of Benefits (EOB): Statements that show how Wellmark applied your health care benefits to your claims.
Fixed Copayment: A set dollar amount you pay for a service. For example, $10 for a generic prescription; or $15 for a doctor's office visit.
Flexible Spending Account: An employee benefit offered by many employers that allows you to set aside money pre-tax to pay for certain qualified health care expenses.
Formulary: A list of prescription drugs approved for coverage under a prescription drug plan.
Generic Alternative: A medication belonging to the same chemical family as a similar brand name drug. A new prescription is needed to move to a generic alternative.
Generic Equivalent: A medication that contains the same active ingredient at the same dose and formulation as a brand-name drug. Moving to a generic equivalent does not require a new prescription. The pharmacist can make the change when the prescription is filled.
Grace Period: Employers may choose to allow employees up to an additional 2 1/2 months after the end of the plan year to incur and be reimbursed for eligible expenses from their flexible spending accounts. This helps employees avoid losing unused flex account contributions.
Hawk-i: Health care coverage for uninsured children in Iowa whose family meet hawk-i income limits and are not eligible for Medicaid.
Health and Wellness Benefits: Programs or services made available that are intended to help you maintain or improve your quality of life. Examples include health support programs for chronic conditions like diabetes or asthma, or the pregnancy care program.
Health Savings Account (HSA): A tax advantaged savings account used to set aside money to pay for qualified medical expenses. You must be enrolled in a qualified high-deductible health plan to open an HSA and not be covered by any other non-qualified coverage.
Health Reimbursement Arrangement (HRA): An account funded by your employer to help you pay for your health care expenses. Your employer funds your HRA with a set annual amount (for example, $500 or $1,000), and determines what qualifies for reimbursement. You can use this money to pay your out-of-pocket medical expenses, such as deductibles, copays or coinsurance for office visits, prescription drugs, and other services.
High-Deductible Health Plan (HDHP): This kind of plan has a deductible higher than typical health plans. Instead of paying copayments, you typically pay the full cost of your medical expenses, up to the plan deductible.
Lifetime Maximum: The maximum amount a health plan will cover for an insured individual during his or her lifetime (for example, $5 million).
Limited-Purpose Flexible Spending Account: An employee benefit that allows you to pay for specific medical expenses pre-tax. A limited-purpose flexible spending account is used with a health savings account (HSA) to pay for allowable health care expenses, such as dental care and vision expenses.
Maintenance Medications: Prescriptions that are used on a continuous basis to treat long term medical conditions or illnesses (for example: high blood pressure).
Managed Care: A health care plan that focuses on helping to contain costs. Managed care plans may require you to see a primary care provider (PCP) before seeking specialty care, and may not provide coverage if you visit out-of-network providers.
Medical Reimbursement Account: An employee benefit offered by many employers that allows you to pay for eligible medical expenses pre-tax. You estimate how much you will spend on qualified medical expenses in the coming year and decide on a contribution amount. When you have an eligible expense, you submit a claim form and, once approved, are reimbursed with tax-free dollars from your account.
Medical Underwriting: Review of an individual's medical background in order to qualify them for health insurance.
Medicare Part D: Medicare-approved plans that you purchase to provide additional coverage for prescription drugs.
Medicare Supplement: Also known as Medigap or Med Supp. Med Supp is supplemental coverage that you purchase to help with "coverage gaps" such as deductibles, coinsurance, and routine physicals that original Medicare does not cover.
Member: An individual who is covered by a health plan.
Network: Doctors and hospitals contract with your health plan to provide services at a discounted rate. Depending on your health plan, you may be responsible for the full cost of your care or pay more out-of-pocket if you visit a doctor or hospital outside of the network.
Network – Pharmacy: Wellmark's pharmacy benefit manager, Catamaran Rx, contracts with more than 60,000 pharmacies in the U.S. These are known as network pharmacies. Depending on your prescription drug plan, you may be responsible for the full cost of your prescription or more money out of your pocket if you use a non-network pharmacy.
Open Enrollment: A one-time-only, 6-month period when federal law allows you to buy any Medigap policy you want that is sold in your state. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems.
Original Medicare: Health coverage offered by the federal government for people over age 65 and those with certain disabilites. Original Medicare includes Part A (hospital) and Part B (doctor) coverage. Original Medicare does not cover all medical costs.
Out-of-Pocket Expenses: The amount you pay for covered services and benefits, including deductibles, copayments, and coinsurance.
Out-of-Pocket Maximum: The maximum amount of your medical costs that you are responsible for paying for covered, in-network services during the calendar year before your health plan pays 100%.
Primary Care Provider (PCP): A physician or other medical professional you select to serve as your starting point when you need medical care. A PCP typically handles a variety of health issues and provides referrals to specialists when needed.
Personal Health Assessment (PHA): An online assessment that provides a snapshot of your overall health and guidance on ways you can improve it.
Protected Health Information (PHI): Health information that could be used to identify an individual. Examples may include details about an individual’s health condition, health care they have obtained, or future payment for health care they obtain. HIPAA regulations govern access to this type of information.
Policy: An official document that provides you with details about covered and non-covered services under your health plan, as well as your out-of-pocket costs and information on how your health insurance plan is administered. You can request a copy of your policy by calling the customer service number on your ID card.
Preferred Provider Organization (PPO): A health plan in which your out-of-pocket costs are lowest when you visit network providers (doctors and hospitals who contract with your health plan to be paid at a certain rate), but also provides coverage if you visit providers who are not part of the network.
Premium: The amount you and/or your employer pay each month for your health insurance.
Premium-Only Plan: An employee benefit many employers offer that allows the portion you pay for group insurance to be taken out of your paycheck before state and federal taxes are withheld.
Preventive Care: Health care services focused on prevention and early detection, such as routine physical exams, immunizations, and screenings.
Primary Care: Services provided by general, and internal medicine practitioners; obstetricians and gynecologists, pediatricians, nurse practitioners, and physician assistants.
Prior Authorization: For specific drugs, your physician must obtain approval to prescribe the medication for you in order for it to be covered.
Provider: Health professionals who provide health care services, such as doctors, hospitals, nurse practitioners, chiropractors, and other health care professionals.
Qualified High-Deductible Health Plan: A high-deductible health plan that makes you eligible to open a Health Savings Account (HSA) to pay for qualified medical expenses tax-free. In order to qualify, the plan must meet regulatory minimum deductible and maximum out of pocket amounts.
Qualifying Life Event: An event that allows you to change your benefit elections during the plan year, such as marriage, divorce, or the birth of a child.
Referral: A type of pre-approval you may be required to get from your primary care provider (PCP) before seeing a specialist.
Specialty Drugs: Utilized by a small percentage of the population for complex and/or chronic conditions (like multiple sclerosis, hepatitis C, rheumatoid arthritis, organ transplants) requiring expensive and/or complicated drug regimens.
Step Therapy: A pharmacy program that may require you to first try a more cost-effective medication before moving to a more expensive drug, if necessary.
Tier: Medications are assigned to certain tiers, or levels, which determine how much you will pay for a prescription. The higher the tier number, the higher your copayment or coinsurance.
Tiered Copayment: The amount you pay for a presciption drug varies according to the tier the drug is on. For example, you might pay $10 for a generic prescription and $40 for a name-brand drug.
Well-Child Care: Certain covered services included in your health plan that help you in protecting your child's health. For example, physical exams, immunizations, and laboratory services.
Underwriting: Review of an individual’s medical background in order to qualify them for health insurance.