Affordable Care Act
A federal law that requires most U.S. citizens and residents to have health insurance. The law also created health insurance marketplaces (or exchanges). In Connecticut, the exchange is called Access Health CT, where you can buy health insurance and possibly receive help paying for it, depending on your income.
Health services that do not require you to stay overnight in a hospital. You might receive these services in a hospital setting or at a free-standing facility, such as a walk-in clinic.
A registered nurse (RN) or social worker at ConnectiCare who works with you and your doctor. This person helps coordinate your care and can educate you about your health condition.
A request to have health insurance pay for health care services. The request can come from you, your doctor, or another health care provider.
Explains the services you received, how much the doctor (or other health care provider) billed your health insurance, how much health insurance paid, and how much, if any, that you are responsible for paying.
A federal law that gives you the right to continue group health insurance coverage for a certain period of time if an employer terminates your job.
A sharing of health care costs in which you and your insurance company each pay a percentage.
Contract or benefit plan year
The 12-month period that begins on the effective date of your health insurance plan.
Copayment or copay
A fixed amount that you pay for a certain health care service.
The portion that are you responsible for paying toward your health care before your health insurance company starts to pay its share. There are different kinds of cost-shares, such as copayments, coinsurance and deductibles. See definitions for each.
A specific dollar amount that you have to pay each year for your health care expenses before your insurance company starts to pay.
A spouse, child, adopted child, or stepchild of the person who carries the health insurance coverage.
Drug tiers indicate what you have to pay toward the cost of a prescription drug covered by your plan. Most of our prescription drug plans have four tiers, with drugs in tier one costing you the least and drugs in tier four costing you the most.
Flexible spending account (FSA)
A special account you use to pay for certain medical and dental costs not covered by your health insurance plan. You contribute the money to your FSA, and all of it must be used by the end of the plan year or you will lose it. FSA money is not taxed, so when you pay for health care it's like getting a discount.
An online questionnaire that provides information about your current health. By answering a series of questions you receive a personal health score, a comparison with others of your age and gender, and recommendations for healthier living.
Health maintenance organization (HMO)
A type of health insurance plan that allows you to see any doctor or other health care provider who participates in the plan’s network.
Health reimbursement account (HRA)
A tax-free account that you can use to pay for qualified health care expenses. Your employer chooses to offer an HRA and sets the amount of funding in it. Your employer's healh benefit plan says what expenses you can may from your HRA. Those may include deductibles, copays, coinsurance, prescription drugs, doctor's visits, and hospital costs.
Health savings account (HSA)
A tax-free savings account that you may use with a high-deductible health plan (HDHP). The HSA allows you to set aside pre-tax money to pay for qualified health care expenses not covered by the health plan.
High-deductible health plan (HDHP)
A type of health insurance plan that requires you to pay a higher dollar amount for your care before the plan starts to pay. In exchange, you generally pay a lower monthly premium for the plan than you would for other types of plans. ConnectiCare offers HMO HDHP plans, which allow you to see any health care provider in our network; and POS HDHP plans, which allow you to see any health care provider, in- or out-of-network.
Doctors and other health care providers who participate in a health insurance plan's provider network and agree to accept the plan's negotiated payment for services. You typically pay less out of your pocket, if anything, when you use in-network providers.
Established by the Affordable Care Act in Connecticut and other states to help people purchase health insurance. ConnectiCare offers a number of insurance plan options on Connecticut's public exchange, Access Health CT.
Managed care plan
A plan in which the health insurance company pays participating doctors negotiated rates for health care services. All of ConnectiCare's products are managed care plans.
Maximum allowable amount
The most that the health insurance plan will agree to pay an out-of-network doctor for a certain service. You may be responsible for paying any balance of the doctor's charges.
Medically necessary medical necessity
Health care services that a doctor provides to prevent, diagnose, or treat an illness, injury, or disease. The services must be clinically appropriate and reflect common medical practice.
A person who is eligible to receive health care services under a health insurance plan.
Off-cycle plan change
When you request a change to your health insurance plan outside of the annual open enrollment period. A common reason is to add someone to your plan because of marriage or birth of child. These reasons are often called "qualifying life events.
A certain period each year when you can enroll in a health insurance plan, add family members, or make other changes to your coverage. The choices you make will be in effect until open enrollment of the following year.
Doctors and other health care providers who do not participate in a health insurance plan's provider network. You may be required to pay more out of your pocket when you use out-of-network providers.
Limits the total amount you have to pay each calendar year for health care expenses, including deductibles, copayments, and coinsurance. Monthly health insurance premiums do not count toward the out-of-pocket maximum.
Health care services that do not require you to be admitted to the hospital.
The part of a health insurance plan that covers prescription drugs.
The kind of coverage you have. ConnectiCare offers a number of plan types, including HMO, POS, PPO, HMO high-deductible, POS upfront deductible, and others. Your member ID card shows what plan type you have.
Point-of-service (POS) plan
A health insurance plan that gives the choice to see any health care provider, in- or out-of-network. Members pay less out-of-pocket, if anything, when they use in-network providers.
The monthly fee that is paid to the health insurance to provide your health coverage.
Prescription drug list
A list of prescription drugs that are covered by your health insurance plan. The category, or "tier," a drug is listed in determines how much you will have to pay toward it. Higher tiers mean you will have to spend more out of your pocket.
Care that your doctor provides to prevent illness or injury, as opposed to treating or diagnosing it. Examples include routine checkups, immunizations, and screenings, such as mammograms and colonoscopies. Your ConnectiCare health plan covers most preventive care services for free.
Primary care provider or PCP
A physician, physician’s assistant, or advanced practice registered nurse (APRN) who is your main contact for health care. Your PCP can do everything from writing prescriptions to referring you to a specialist when necessary. This is the person who knows the most about your health history and helps you navigate the health care system.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. This is also sometimes called preauthorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Prior authorization isn’t a promise your health insurance or plan will cover the cost.
A health care professional or facility that provide you with health care services. There are many types of providers, from hospitals and nursing homes to doctors and mental health counselors.
Qualified medical expenses
Determined by the IRS, these are expenses that you can pay for using money from a health savings account (HSA), health reimbursement account (HRA), or flexible spending account.
A change in your life that can make you eligible to enroll in or change your health coverage outside of the open enrollment period. Examples include the birth of a child, marriage, divorce, or becoming eligible for Medicare. There are others, too.
Prescription drugs used to treat complex, chronic conditions like rheumatoid arthritis, multiple sclerosis, and cancer. Usually your doctor will need to ask ConnectiCare for prior authorization for these drugs.
An individual who enrolls in a health insurance plan and is eligible to receive covered health care services. Also known as the policyholder, this person may have dependents who are members of the plan.
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.
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.
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.
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.
Coordinated Care Plan
A plan that includes a Centers for Medicare & Medicaid Services (CMS) approved network of providers that are under contract or arrangement with the M+C organization to deliver the benefit package approved by CMS. Coordinated care plans include plans offered by health maintenance organizations (HMOs), provider-sponsored organizations (PSOs), preferred provider organizations (PPOs), as well as other types of network plans (except network MSA plans).
A flat fee paid by a member for certain plan benefits.
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.
Covered services that are rendered by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition.
A health care program in which employers or individuals contract with health maintenance organizations (HMOs) for prepaid benefit plans, funded by the HMOs.
Health plan Employer Data and Information Set — developed by NCQA (National Committee for Quality Assurance) with considerable input from the employers. 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.
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.
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.
Medicare Beneficiary (or Eligible)
Any person who is age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant) are eligible to receive Medicare coverage.
Medicare Advantage Plan
A Medicare program that gives members more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.
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.
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.
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.
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.
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.
The benefits program operated by ConnectiCare for arranging for health services for members upon which the employer and ConnectiCare have agreed.
Health services as specified in the Membership Agreement or other Plan document.
Pharmacy Drug Program (PDP)
A program that offers prescription drug coverage for Medicare beneficiaries. Such programs must offer drug coverage equal to or greater than the Medicare standard plan. The network of pharmacies within the PDP must meet federal standards.
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 sub- stance abuse services, from ConnectiCare’s behavioral health program, needed in advance of the member’s receipt of health services from a non-participating provider (out-of-plan services).
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.
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.
A participating physician other than the member’s PCP.
Urgently Needed Care
Urgently needed care refers to a non-emergency situation where the member is inside the United States, the member is temporarily absent from the Plan’s authorized service area, the member needs medical attention right away for an unforeseen illness, injury, or condition, and it isn’t reasonable given the situation for the member to obtain medical care through the Plan’s participating provider network. Note: Under unusual and extraordinary circumstances, care may be considered urgently needed when the member is in the service area, but the provider network of the Plan is temporarily unavailable or inaccessible.
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership
Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.