Glossary

Allowed Amount: (also called the “reasonable and customary” amount). The amount the enhanced Anthem PPO Plan uses to determine benefit payments for care or services received from out-of-network providers. You are responsible for paying any amounts over the “allowed amount.”

Calendar Year Deductible: The amount you pay for covered medical care and services each plan year before the plan pays benefits. Once you have met the deductible, you share the cost of covered medical care and services with the plan through coinsurance or copays. For some plans, not every covered service is subject to the deductible. For example, many medical and dental plans do not require that the deductible be met before the plan pays for preventive care services. Keep in mind there is an individual deductible and a combined family deductible.

Calendar Year Out-of-Pocket Maximum: The most you pay out-of-pocket for deductibles, copays and coinsurance each plan year for covered healthcare expenses. When you meet the out-of-pocket maximum, the plan will pay 100% of covered expenses for the rest of the plan year. Keep in mind there is an individual out-of-pocket maximum and a combined family out-of-pocket maximum.

Coinsurance: The percentage of the cost you pay (rather than a flat dollar copay) when you receive certain covered healthcare services. Generally, you start paying coinsurance after you meet your annual deductible. (See “Calendar Year Deductible,” above.)

Copay: The flat-dollar amount you pay when you receive certain covered healthcare services or when you fill a drug prescription.

Dental Preferred Provider Organization (DPPO): A dental plan that pays benefits when you receive care from in-network or out-of-network providers. The plan pays higher benefits for in-network care.

Direct Compensation (DC) Plan: This refers to UnitedHealthcare’s copayment dental plan that pays benefits only when you see network providers (except for emergencies); it’s available only in California and Nevada. The plan’s full name is the “Select Managed Care Direct Compensation Plan.”

EOB: The “Explanation of Benefits” statement sent to you by your health plan administrator (e.g., Anthem Blue Cross/Blue Shield) after they have processed a claim for you. The EOB explains the payments made for the healthcare treatments and/or services provided to you or your covered dependents, discounts applied if you used a network or PPO provider, and it shows what you may owe. An EOB is not a bill for healthcare services.

Formulary: The list of prescription drugs covered by a prescription drug plan. The formulary is designed to help doctors prescribe drugs that are medically necessary and cost-effective. Formularies are updated periodically.

Formulary Brand Name Drug: Food and Drug Administration (FDA)-approved prescription drugs marketed under a specific brand name by the manufacturer and included on the prescription drug plan administrator’s list of covered prescription drugs.

Generic Drug: The FDA-approved therapeutic equivalent of a brand name prescription drug. It contains the same active ingredients as the brand name drug, but costs you and the plan substantially less.

Health Maintenance Organization (HMO): A medical plan that pays benefits only when you see in-network providers and receive in-network services (except for emergency care).

In-Network: Providers or facilities that contract with a health plan to provide services at pre-negotiated fees. You usually pay less when using in-network providers.

In-Network Only (INO) Plan: This refers to UnitedHealthcare’s copayment dental plan (also known as a Dental Health Maintenance Organization, or DHMO Plan). This plan pays benefits only when you see network providers (except for emergencies); it is not available in all states.

Insurance Carrier: A company that administers claims and payments for benefit plans. When a plan is fully insured, the insurance carrier also insures the benefits plan and uses its money to pay the plan’s claims.

Non-Formulary Brand Name Drug: FDA-approved prescription drugs marketed under a specific brand name by the manufacturer and not included on the prescription drug plan administrator’s list of covered prescription drugs. 

Open Enrollment: A specified time period (for the Trust Fund it’s usually in November), when you can change your healthcare benefit elections without having a Qualifying Status Change. (See "Qualifying Status Change," below.)

Out-of-Network: Doctors, hospitals, labs and other healthcare facilities that are not in your health plan’s network of providers. For some plans, services received out-of-network are not covered at all, and for other plans, there is coverage, but at a lesser amount than if you used an in-network provider.

Preferred Provider Organization (PPO): A medical plan that pays benefits when you receive care from in-network or out-of-network providers. The plan pays higher benefits for in-network care.

Preventive Care: As defined by the Affordable Care Act, preventive care is care that has an A or B rating from the U.S. Preventive Services Task Force, including most common preventive services and tests such as an annual physical; routine and age-appropriate immunizations; and age- and gender-appropriate routine tests such as a colonoscopy and mammogram. Preventive care is covered at 100% with no copay, deductible or coinsurance when received from an in-network provider.

Primary Care Provider (PCP): A doctor, nurse practitioner or physician’s assistant that you typically see first when you need care. This provider is in the best position to coordinate all your medical care because he or she has a full picture of your health issues and the medications you may be taking.

Qualifying Status Change: A life event, as defined by the Internal Revenue Service, that allows you to change your healthcare coverage outside of the annual Open Enrollment period. Qualifying life events include marriage, legal separation, divorce, birth or adoption of a child, death of a dependent, and becoming eligible for or losing other healthcare coverage.

Self-funding: An arrangement where the Trust Fund provides claims payments to providers or participants using the Trust Fund’s money. Under this arrangement, the benefits administrator (typically an insurance company) is engaged to process claims and benefit payments on behalf of a plan.

Specialty Drugs: These are costly prescription drugs often given by injection or infusion to treat complex, chronic conditions such as cancer, hemophilia, HIV, rheumatoid arthritis and multiple sclerosis. Specialty drugs may require special handling, including temperature control.

Telemedicine: Visiting a healthcare provider via video chat, using a mobile phone, tablet or computer. The provider evaluates, diagnoses and treats patients without the need for an in-person visit.

Transition of Care: This means coordination and continuity of healthcare during a change from one healthcare setting or provider to another. If you’ll be covered under the Anthem PPO and your healthcare provider is not currently in Anthem’s network, and you’re being treated for a serious or chronic illness or certain condition that’s expected to last past December 31, 2018, Anthem has a dedicated team to help provide you with transition of care. Plus, you may be eligible for Anthem’s Continuity/Transition of Care Assistance Program, which covers certain out-of-network care at the in-network benefits level. For more information, see the announcement brochure you received in late August.

Rate this page