Product name offering
HMO Health Plan consisting of Plan Administration, Customer Service, Account Management, Billing/Finance, Facility Claims, etc.
Physician Group and sole organization driving physician services (and guidance) for those enrolled in the KelseyCare powered by Community Health Choice product.
Maximum amount on which payment is based for covered health care services. This may be called "eligible expense," "payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.
An oral or written request for your health insurance plan to review a decision or a grievance again.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. For example, if the health insurance or plan’s allowed amount for an office visit is $100, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
An oral or written expression of dissatisfaction with any part of the health plan.
Conditions due to pregnancy, labor, and/or delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency Caesarean section aren’t complications of pregnancy.
A fixed amount (for example, $15) you pay for a covered health care service, usually at the time you receive the service. The amount can vary by the type of covered health care service.
A family member who meets your employer’s requirements to be included in your health care plan. You must specifically list them in your enrollment documents.
The amount you pay for a service before any insurance starts to pay. KelseyCare ERS members have no deductibles, except with the Prescription Drug Benefit.
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Ambulance or air ambulance used for transport in a medical emergency.
Emergency services you get in an emergency room.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Health care services that your health insurance or plan doesn't pay for or cover.
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Care in a hospital that usually doesn’t require an overnight stay.
Maintenance medications are those that you must take on a continuous basis to maintain your health. Examples include medications for diabetes and blood pressure. Non-maintenance medications are taken for a short duration to address a short-term illness. Examples include medications for infections or pain.
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance- billed charges, or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. KelseyCare ERS Members will pay the entire cost of seeing an out-of-network provider.
Health care services a licensed medical physician (M.D.– Medical Doctor or D.O.– Doctor of Osteopathic Medicine) provides or coordinates.
The health plan often requires additional information from your provider to determine if a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Your health insurance or plan may require prior authorization for certain services before you receive them, except in an emergency.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Health insurance or plan that helps pay for prescription drugs and medications.
Drugs and medications that by law require a prescription.
A physician (M.D. – Medical Doctor or D.O.– Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
A physician (M.D. – Medical Doctor or D.O.– Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
A physician (M.D.– Medical Doctor or D.O.– Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Medical services required for the immediate treatment of a medical condition that requires prompt medical attention but where a brief time lapse before receiving services will not endanger life or permanent health.