The acquire date is the date that establishes a relationship between you and your dependents, such as date of marriage for a spouse, date of birth for a natural child or date of legal obligation if you are appointed as a guardian.
Sometimes called “surprise billing,” balance billing can happen when you can’t control who is involved in your care, like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Out-of-network providers may be permitted to bill you for the difference between what your plan has agreed to pay and the full amount charged for a service. For example, the full charge for a service is $100, and your plan has agreed to pay $45. You may owe the difference of $55. The good news is that you have protections from balance billing in certain situations. See the model billing notice on the Partners for Health website at https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/surprise_billing_model_notice.pdf to learn more about your rights and protections.
Claims are the bills received by your insurance carrier(s) after you obtain services.
Coinsurance is your share of the cost for a service or supply covered by insurance, calculated as a percentage. An example of coinsurance is 20% of the allowed amount. Generally, if coinsurance applies to a service, you will have to “meet” or “satisfy” a deductible first. In other words, you will pay your deductible plus coinsurance.
Consumer-Driven Health Plan, or CDHP
A consumer-driven health plan, or CDHP is a type of health insurance plan that allows employees to use pretax money to help pay for qualified medical expenses. A CDHP typically has a higher deductible and lower monthly premiums. You take responsibility for covering minor or routine health care expenses until your deductible is met. Once you meet your deductible, coinsurance applies.
A copay is a fixed amount you pay for covered health care services, usually when you receive the services. An example of a copayment is $25.
A deductible is a fixed dollar amount you must pay each year before the plan pays for services that require coinsurance. Amounts paid for ineligible expenses do not count toward your deductible, and there are separate deductibles for in-network and out-of-network services.
The drug list is a list of covered drugs. The listing includes generic and preferred brand drugs covered by the plan. This list is often called a formulary.
The drugs covered by the state’s pharmacy benefit are grouped into tiers — generic, preferred brand, non-preferred brand and specialty. Each tier has a different payment amount.
Under a fully-insured plan, an insurance company, rather than a group sponsor like the state, assumes financial risk and pays claims in exchange for pre-paid premiums. The sponsor pays a premium to the insurance company. The state’s dental plans are fully insured.
Generic Drug (Tier One)
A tier one generic drug is approved by the Food and Drug Administration and equal to the brand name product in safety, effectiveness, quality and performance. You pay the least when you fill a prescription with a generic drug.
Guaranteed issue means that you cannot be denied coverage and do not have to answer questions about your health history provided you enroll within a certain amount of time. The state’s voluntary term life insurance is guaranteed issue.
Head of Contract
The head of contract is the employee, retiree or surviving dependent who elects coverage and has authority to change coverage elections. Two married employees who both work for participating employer groups could each be the head of their own contract or one could be the head of contract and the other a covered dependent spouse.
Health Insurance Portability and Accountability Act, or HIPAA
The Health Insurance Portability and Accountability Act of 1996 is a federal law that gives patients more control over their health information. It sets boundaries on the use and disclosure of health information, establishes appropriate safeguards to protect the privacy of health information and holds violators accountable with civil and criminal penalties that can be imposed if they violate a member’s privacy rights. The law also governs portability between health plans and special enrollment provisions.
In-network care is provided by a network provider. Costs for in-network care are usually less expensive than out-of-network care because of special agreements between insurance carriers and providers.
Maximum Allowable Charge, or MAC
The maximum allowable charge is the highest dollar amount of reimbursement allowed for a particular covered service. The MAC is based on fees negotiated between a claims administrator and certain physicians, health care professionals or other providers and whether covered services are received from providers contracting with the claims administrator or not contracting with the claims administrator. You pay more if you go to an out-of-network provider.
Meeting Your Deductible
Meeting your deductible means you have paid out the amount you are responsible for each year before your plan pays for eligible health care expenses subject to a deductible. Once you meet your annual deductible, you will only coinsurance.
A network is a group of doctors, hospitals and other healthcare providers contracted with a health insurance carrier to provide services to plan members for set fees.
Non-Preferred Brand Drug
A tier three non-preferred brand drug belongs to the most expensive group of drugs. These drugs are not included on the preferred drug list. You will pay the most if your prescription is filled with a non-preferred brand.
Out-of-network care refers to healthcare services from a provider who is not contracted with your insurance carrier. Costs for out-of-network care are usually more than for in-network care. The benefits paid are usually based on the maximum allowed by the plan. When out-of-network charges are higher than the maximum allowed, the member pays the difference.
An out-of-pocket maximum is the most you will pay for services in any given year. The out-of-pocket maximum includes your deductible but does not include premiums or amounts you pay for non-covered expenses. Once you reach your out-of-pocket maximum, the plan pays 100% of your eligible expenses for the rest of the year. There are separate maximums for in-network and out-of-network services.
In the broadest sense of the word, plan is the state of Tennessee insurance program. Depending on context, plan may also refer specifically to medical benefits or specific group coverage such as the state plan, the local education plan or the local government plan. Plan may also be used to describe plan design options as in PPO plan or CDHP plan, or it may be used to describe voluntary benefits, such as dental plan or vision plan.
Preferred Brand Drug
A tier two preferred brand drug belongs to a group of drugs that cost more than generics but less than non-preferred brands. Many popular and highly used preferred brands are included on the preferred drug list.
Preferred Provider Organization
A preferred provider organization is a network of health care facilities and medical professionals known as preferred providers. Those providers contract with health insurance companies to offer services to plan members at reduced rates. Under the state’s PPO plan options, you pay either a copayment or a deductible and coinsurance for covered services.
Premium is the amount you pay each month for your coverage, whether or not you receive health services. What you pay depends on where you work (state, higher education, local education or local government) and the plan design option, network and coverage level you select.
Preventive care is routine heath care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease or other health problems. For example, preventive care includes screening mammograms and colonoscopies, as well as regular blood pressure checks. In many cases, preventive care helps avoid a serious or even life-threatening disease.
Primary Care Physician
Primary care physician refers to your regular medical doctor. This is the doctor you see most often. A PCP can be a general practitioner, a doctor who practices family medicine, internal medicine or pediatrics or an OB/GYN. Nurse practitioners, physician’s assistants and nurse midwives licensed by health care facilities may also be considered primary-type providers when working under the supervision of a PCP.
Under a self-insured plan, a group sponsor or employer like the state, rather than an insurance company, is financially responsible for paying the plan’s expenses, including claims and plan administration costs. The state’s health insurance plans are self-insured.
Special Enrollment Provision
A special enrollment provision is a part of the federal HIPAA law that allows persons to request enrollment beyond an initial eligibility period or outside of an annual enrollment period if certain conditions are met and there is a loss of eligibility for other coverage or new dependents are acquired.
Special Qualifying Event
A special qualifying event is a change in a person’s situation, such as getting married or having a baby or an event like a divorce or termination of employment that results in losing eligibility for health coverage, which may allow persons to elect benefits or change benefit elections.