Understanding Your Colorado Health Insurance Terms 2019 | Rocky Mountain Health Plans

Understanding Your Colorado Health Insurance Terms 2019 | Rocky Mountain Health Plans

By RMHP

Whether you’re a novice to navigating your health care and Colorado health insurance or you know your way around an evidence of benefit (EOB) summary pretty well, it always helps to freshen up on the industry terminology.

Plus, when it comes to health insurance, empowering yourself with knowledge is the most greatest way to stay in control of your health, potential medical service coverage, prescription drug costs, etc. Review the terminology below to help you get your best foot forward to taking control of your health care in 2019.

Authorization:

Health plan approval necessary prior to the receipt of care.

Certificate of Creditable Coverage:

A written certificate issued by a group health plan or health insurance plan that states the period of time you were covered by your health plan.

Coinsurance:

The amount you may be required to pay for services after you pay any plan deductibles. This is typically a percentage of the allowed cost of the service provided.

Coordination of Benefits:

The method for determining which insurance company is primarily responsible for payment of services when a Member is covered under more than one policy.

Copayment:

The amount you pay for a medical service, such as a doctor visit, lab, X-ray, prescription, etc. This is usually a set amount according to your benefit plan.

Deductible:

The amount you must pay for health care or prescriptions, before your prescription drug plan or insurance plan begins to pay if your plan has a deductible. Not every benefit may apply to your deductible.

Disposable Medical Supplies:

Any medical equipment this used only once or a limited number of times before being disposed. This may include items such as diabetic testing supplies, ostomy supplies, or needles.

Durable Medical Equipment (DME):

Medical equipment that ordered by a doctor for use in the home, which includes tools like walkers, wheelchairs, or hospital beds.

Emergency Care:

Any care you reasonably believe is an emergency and when you believe your health is in serious danger. You should use the Emergency Room when your condition is so serious that you are not able to call your doctor or he or she tells you to go to the Emergency Room. Learn more about the differences as to when you should visit the Emergency Room versus an Urgent Care.

Explanation of Benefits (EOB):

An EOB is sent to you each time you receive services. The EOB details services received and provides amounts owed, by you, for these services. You will receive an EOB monthly but only if services were paid by your health insurance company, such as RMHP, within the previous month. However, some plans don’t necessarily receive an EOB. To learn more about specifics of your plan, contact us by calling 800-346-4643 (TTY:711).

Formulary:

A list of drugs and prescription medications covered by your health benefit plan (including injectable medication).

Health Insurance Portability and Accountability Act (HIPAA):

Health Insurance Portability and Accountability Act (HIPPA) of 1996 is U.S. government legislation that ensures a person's right to buy health insurance after losing a job, establishes standards for electronic medical records, and protects the privacy of a patient's health information.

Health Savings Account (HSA):

A tax-exempt bank account established specifically for the purpose of paying qualified medical expenses.

Inpatient Care:

Health care that you get when you are admitted to a hospital or skilled nursing facility.

Lifetime Maximum:

The maximum dollar amount your health insurance pays for one individual.

Medically Necessary:

Services or supplies needed for the diagnosis and/or treatment of your medical condition.

Member Billing Statement (MBS):

Your MBS shows you the health care services you or a dependent may have received and the deductibles or copayments due to your health insurance company. Your MBS is usually mailed monthly and only if services have been considered for payment within the previous month. The provider of services will have already been paid and your Member responsibility is owed directly to your insurance company. Although not all plans receive an MBS.

Non-Formulary Drugs:

Prescription medications and drugs not covered on your plan-approved drug list or formulary.

Non-Participating:

Providers who do not contract with RMHP or are located out-of-state are non-participating and a preauthorization may be needed in order for RMHP to consider payment of claims.

Office Visit Copay:

The amount you will pay each time you see a doctor. Copays are usually a flat dollar amount, like $35 per visit. There are no copays on HSA plans.

Out of Pocket Maximum (annual):

This is the maximum amount that you pay per plan year if your benefit covers an out-of-pocket maximum. This does not include plan premiums. This may include deductibles. RMHP provides coverage-in-full after you have met your annual out-of-pocket maximum.

Outpatient Hospital Care:

Medical or surgical care furnished by a hospital, when you have not been admitted to the hospital.

Participating:

Providers contracting with your health insurance carrier are considered in-network for Members.

Participating Provider:

Physicians, hospitals, clinics, and licensed clinicians that contract with your insurance provider to deliver care to Members.

Preauthorization:

A preauthorization is permission to see a specific doctor for certain services requiring review and approval prior to receiving those services. A preauthorization is usually required, based on your plan type, to see a non-participating provider.

Premium:

The monthly cost of a health plan.

Prescription Drug Options:

RMHP Family plans offers several drug plans to pair with your RMHP Family health plan. The Prescription Drug Plan Description Form provides detailed benefit information about each plan.

Primary Care Physician (PCP):

A doctor that trained to give you basic care. Your PCP is the doctor you see first for most health problems. He or she ensures you get the care you need to keep you healthy and should be the primary point for health care needs.

Skilled Nursing Facility:

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services. This is not a long term or custodial care facility (nursing home).

Specialist:

 A doctor who treats only certain parts of the body, certain health problems, or certain age groups.

Urgent Care:

 If your condition is enough to be of concern but not an emergency, you may go to an Urgent Care provider. These providers are available after hours and usually on weekends. Receiving Urgent Care is generally less expensive than going to the Emergency Room.

Value Added Services:

Services provided at no additional charge. Value-added services vary by plan.

Still have questions? Contact RMHP today by calling 800-346-4643 (TTY:711). We’re here to help you be at your healthy best and want to empower you to make decisions that help you stay well.

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