Glossary

Ambulatory Surgery Center (ASC) - An Ambulatory Surgery Center (ASC) is an entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center does not exceed 24 hours. It is a facility that is not owned by a hospital, and bills for its services under its own unique tax identification number.

CAQH - The Council for Affordable Quality Healthcare (CAQH) is an organization ConnectiCare contracts with for obtaining credentialing applications of new providers. It is an online system that eliminates the need for health care providers to fill out and submit multiple paper applications for participating health plans.

Case Management - The process for identifying members with specific health care needs in order to help in the development and implementation of a plan that efficiently uses health care resources to achieve favorable member outcomes.

Case Manager - An individual, usually a registered nurse, who is responsible for developing and implementing a plan that takes into account the benefit structure, accepted industry and internal standards, and cost effectiveness in order to achieve favorable member outcomes.

Coinsurance - The percentage of the cost of plan benefits for which a member is responsible after any applicable deductible is met. When coinsurance applies as a result of the in-network level of benefit, except as otherwise required by law, the coinsurance amount shall be calculated based on the lesser of provider’s charges for health services or ConnectiCare’s negotiated amount with providers for such services.

When coinsurance applies as a result of the out-of-network level of benefit, except as otherwise required by law, the coinsurance amount will be calculated based on the Maximum Allowable Amount.

Copayment - A flat fee paid by a member for certain plan benefits.

Deductible - The total amount which must be paid by a member during the calendar year for certain plan benefits before ConnectiCare will begin paying for those plan benefits.

Fully-insured - A health care program in which employers or individuals contract with health maintenance organizations (HMOs) for prepaid benefit plans, funded by the HMOs.

HEDIS® - Health plan Employer Data and Information Set — developed by NCQA (National Committee for Quality Assurance) with considerable input from the employer community. HEDIS is designed to provide some standardization in performance reporting for membership, utilization, financial, and clinical data so that employers and others can compare performance among plans.

HMO Open Access - A ConnectiCare product in which members are required to obtain services from a participating provider, but are not required to obtain a referral for specialty care. Coverage is provided for emergency and out-of-area urgent care received from non-participating providers.

HMO Personal Care Plan - A ConnectiCare product in which members are required to obtain services from a participating provider, and must obtain a referral for most types of specialty care. Coverage is provided for emergency and out-of-area urgent care received from non-participating providers.

Hospital Outpatient Surgical Facility (HOSF) - A Hospital Outpatient Surgical Facility (HOSF) is a facility owned by a hospital or hospital system offering surgical procedures and related care that in the opinion of the attending physician can be safely performed without requiring overnight inpatient hospital care. A hospital outpatient surgical facility is included within the hospital license and the Medicare/Medicaid certification of the hospital itself. Services rendered by the HOSF are billed utilizing the hospital's tax identification number or a tax identification number unique to the hospital or hospital system.

Independent Practice Association (IPA) - An independent practice association or other organization of providers, including but not limited to a physician-hospital organization (PHO) and a group practice, that has entered into a services arrangement with ConnectiCare or a ConnectiCare affiliate or subcontractor to provide health services to members under the  Membership Agreement or other Plan document.

Medically Necessary/Medical Necessity - Term used to describe health services that are required therapeutic treatments for an illness or injury. The health care practitioner determines the medical care, but coverage of the care under ConnectiCare’s plans is subject to medical necessity as determined by ConnectiCare. We use input from local physicians, including specialists, to approve and, in some cases develop our medical necessity protocols. To be medically necessary, treatment must be:

• For illness or injury: This means treatment must be for a diagnosis that is commonly recognized as a disease or injury;
• Therapeutic: This means there must be a reasonable expectation that the treatment will directly result in the restoration of health or function;
• Required: This means there must be no reasonable alternative treatment which is less intensive or invasive;
• Not experimental or investigational; and
• Not primarily for the convenience of the member, the member’s family or a provider rendering services.

Membership Agreement - The document that includes the rights, benefits, terms, conditions and limitations of each ConnectiCare Plan available to members, including the applicable benefit summary, evidence of agreement (employer only), riders, insert pages, and enrollment forms.

National Committee for Quality Assurance - The National Committee for Quality Assurance (NCQA) is an independent not- for-profit organization which performs quality reviews and accredits managed care organizations. NCQA also accredits credentialing verification organizations and develops HEDIS® standards.

Non-participating Physician or Provider - A physician or health care provider who is not a participating physician or a participating provider.

Out-of-Plan Services - Health care services rendered by a non- participating provider, when members are enrolled in any of our HMO plans, where participating providers must be used.

Participating Pharmacy - A pharmacy that has entered into an agreement with ConnectiCare, an IPA or an affiliate or subcontractor of ConnectiCare to provide covered prescription drugs and supplies to members.

Participating Physician - A health care professional duly licensed to practice as a physician, who has entered into an agreement with ConnectiCare, an IPA, or a subcontractor of ConnectiCare to provide certain health services to members.

Participating Provider - A health care practitioner, including a participating physician, participating pharmacy, participating hospital, or other facility that is duly licensed to provide health care services that has entered into an agreement with ConnectiCare, an IPA, or an affiliate  or a subcontractor of ConnectiCare to provide certain health services to members. Participating providers do not include hospital-based clinics, even if the hospital is a participating hospital.

Plan - The benefits program operated by ConnectiCare for arranging for health services for members upon which the employer and ConnectiCare have agreed.

Plan Benefits - Health services as specified in the Membership Agreement or other Plan document.

Point-of-Service Open Access - A ConnectiCare product in which members may utilize participating providers and receive a higher, in-network level of benefits (e.g., copayment); or utilize non-participating providers and receive a lower, out-of- network level of benefits (e.g., deductible and coinsurance). There is no referral requirement for specialty care.

Point-of-Service Personal Care Plan - A ConnectiCare product in which members may utilize participating providers and receive a higher, in-network level of benefits (e.g., copayment); or utilize non-participating providers and receive a lower, out-of- network level of benefits (e.g., deductible and coinsurance). Members are required to obtain a referral for most specialty services, and failure to obtain the referral results in payment at the out-of-network benefit level.

Pre-authorization/Pre-authorized - The authorization, based on medical necessity, needed in advance of the member’s receipt of certain specified health services that is obtained from ConnectiCare, or in the case of mental health and alcohol and substance abuse services from ConnectiCare’s behavioral health program.

Pre-authorization also includes the written authorization from ConnectiCare, or in the case of mental health and alcohol and substance abuse services, from ConnectiCare’s behavioral health program, which is needed in advance of the member’s receipt of health services from a non-participating provider (out-of-plan services).

Pre-certification/Pre-certified - The registration and approval process, based on medical necessity, needed in advance of a member’s partial hospitalization or inpatient admission to a hospital, hospice, residential treatment facility, rehabilitation facility or skilled nursing facility that is obtained from ConnectiCare, or in the case of mental  health and alcohol and substance abuse services from ConnectiCare’s behavioral health program.

Preferred Provider Organization (PPO) - A health care product that requires an enrollee to obtain services from a network of participating providers to receive the highest level of benefits. Enrollees may seek out-of-network providers, but their out-of-pocket costs are higher than if they seek care from in-network providers. In addition, there are no PCP selection or referral requirements under this product.

Primary Care Physician (PCP) - A participating physician, selected by or assigned to the member, who maintains a general practice or who is normally engaged in one of the following specialties: family practice, internal medicine or pediatrics and who is eligible for listing as a PCP in the Provider Directory, as updated from time to time.

Referral - An approval for the member to see specialist physicians and other participating providers that is communicated to ConnectiCare by:

• the member’s Primary Care Provider (or the covering physician designated by the member’s PCP); or,
• an obstetrician/gynecologist who is a participating physician; or,
• ConnectiCare’s behavioral health program for mental health, alcohol and substance abuse care.

This communication must be obtained prior to members receiving health care services from specialist physicians and other participating providers to be eligible for the highest level of benefits.

Self-funded - A health care program in which employers fund benefit plans from their own resources without purchasing insurance. Self-funded plans may be self-administered, or the employer may contract with an outside administrator (a third party administrator: TPA) for an administrative service only (ASO) arrangement. Also known as self-insurance.

Note: These plans are not subject to state benefit mandates, so benefits may vary by employer group. Employers may also "carve out" certain benefits to be supplied by a different network of providers.

Specialist Physician - A participating physician other than the member’s PCP.

Subscriber - An employee who enrolls in a ConnectiCare plan and becomes eligible to receive plan benefits.