Page 27 - PA_PPO_Member_Kit

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Dependent
– a person who receives health coverage through a spouse, parent or other family
member who is the contract holder or policyholder.
Durable Medical Equipment (DME)
– 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.
Emergency Medical Condition
– an illness, injury, symptom or condition so serious that a
reasonable person would seek care right away to avoid severe harm.
Emergency Services
– evaluation of an emergency medical condition and treatment to keep the
condition from getting worse.
Excluded Services
– health care services that your plan doesn’t pay for or cover.
Exclusive Provider Organization (EPO)
– a managed care program where members get care within
a specific provider network. Members use the EPO provider network exclusively, but they don’t need to
choose a PCP. Referrals are not needed for specialty care, but medical services received outside of the
EPO network are not covered.
Generic Drug
– a generic drug has the same active ingredients as the original brand-name drug.
It might use different inactive ingredients, like fillers that may affect the color or shape of the drug.
In other areas, the drug is clinically identical. Generic drugs usually cost 30 to 60 percent less than
brand-name drugs. They are rated by the Food and Drug Administration (FDA) to be as safe and
effective as brand-name drugs.
Grievance
– a complaint that you communicate to your plan.
Health Insurance
– a contract that requires your health insurer to pay some or all of your
health care costs in exchange for a premium.
Health Maintenance Organization (HMO)
– a form of health coverage that emphasizes preventive
care. With an HMO, members prepay a premium for health services, which generally includes inpatient
and outpatient care. For the member, it means reduced out-of-pocket costs and no paperwork.
Hold Harmless
– prevents you from being billed for charges for covered services from an affiliated
provider due to events beyond your control.
Hospital Outpatient Care
– care in a hospital that usually doesn’t need an overnight stay.
Hospitalization
– care in a hospital that requires admission as an inpatient and usually needs an
overnight stay. An overnight stay for observation could be outpatient care.