Glossary of Terms

An appeal is a request to review and reconsider a decision made about a member's request for a healthcare service, supply or device. Members can submit appeals verbally or in writing. An authorized representative or participating provider may file on their behalf.

Behavioral health treatment includes professional services and evidence-based programs — such as applied behavior analysis — designed to develop or restore function, to the maximum extent practicable, for individuals with pervasive developmental disorder or autism.

The benefit year is a 12-month period when a member’s or employer group’s coverage is active for annual benefit accruals and limits. It may align with the calendar year (starting January 1) or begin on a date specified in the employer group’s contract.

A claim is a request for payment that a member or their healthcare provider submits to the health plan.

Coinsurance is a percentage of the cost for covered services members must pay. If a plan includes coinsurance, members will see the percentage listed in their Healthcare Benefits and Coverage Matrix (BCM).

Copayments are specific dollar amounts members pay for each visit to a participating provider or for specific covered services, as outlined in the Healthcare Benefits and Coverage Matrix (BCM). Copayment amounts can vary depending on the service. For example, copayments for doctor visits, emergency room visits and hospital stays may differ.

Cost sharing is the amount members must pay for covered services (e.g., deductibles, copayments or coinsurance). It doesn’t include premium costs.

Covered California, HBEX, Health Benefit Exchange, Health Exchange is the public health insurance marketplace that helps individuals, families and small businesses shop for and enroll in healthcare coverage. In California, this marketplace is called Covered California.

Creditable coverage refers to prescription drug coverage that, on average, is expected to pay as much as standard Medicare Part D coverage, as defined by the Centers for Medicare and Medicaid Services (CMS).

A deductible is the amount members must pay for specific covered services in a benefit year before the health plan begins to pay. Once the deductible is met, members continue paying copayments or coinsurance until they reach the out-of-pocket maximum (OOPM).

A dependent is a subscriber’s spouse, domestic partner or child who’s eligible to enroll in a health plan.

DME refers to the equipment and supplies a healthcare provider orders for everyday or extended use. Coverage for DME may include oxygen equipment, wheelchairs and crutches.

An emergency medical condition involves sudden, severe symptoms (including intense pain) where not receiving immediate medical care could reasonably lead to any of the following:

• Placing the member’s health in serious jeopardy
• Severe dysfunction of any bodily organ or part
• Severe impairment to bodily functions

An emergency medical condition also covers “active labor,” meaning there isn’t enough time for a safe transfer to a participating or designated hospital before delivery or when a transfer could endanger the health of the parent or baby.

A psychiatric emergency medical condition is a mental disorder with severe, acute symptoms that cause the member to meet one of the following criteria:

• An immediate danger to themselves or others
• Immediately unable to provide for or utilize food, shelter or clothing due to the mental disorder

The employee contribution is the portion of the health plan premium that the employee pays, typically deducted from their wages by the employer.

The employer contribution is the portion of an employee’s monthly health plan premium paid for by the employer.

Enrollment is the process of registering an approved applicant or employee and their eligible dependents as members of a health plan.

The Evidence of Coverage and Disclosure Form (EOC) explains how, when and where members can access covered healthcare services. It also outlines plan limitations, exclusions, the process for filing complaints or grievances and other key plan details.

Exclusions are specific conditions, services or treatments not covered by a health plan.

The Explanation of Benefits (EOB) is a statement for members that details the services billed by a healthcare provider, how those charges were processed and the member’s financial responsibility for the claim.

A family includes a subscriber and all of their dependents.

A formulary, or prescription drug list, is a comprehensive list of FDA-approved outpatient prescription drugs. These drugs are evaluated by the Sutter Health Plan Pharmacy and Therapeutics Committee and are eligible for coverage under Sutter Health Plan.

A grievance is any written or oral expression of dissatisfaction, including concerns about the quality of care or requests to review coverage decisions.

A group refers to the entity, typically an employer, that enters into a group health plan contract with a health plan.

A group health plan is a health plan an employer or employee organization provides to cover employees and their dependents, unlike individual or family plans.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law that mandates privacy rules and standards for medical providers and health insurance companies. It aims to streamline industry practices while protecting the privacy and identity of consumers.

Habilitation services are healthcare services that help individuals develop, maintain or improve skills needed for daily living. Services can include physical therapy, occupational therapy, speech-language therapy and other support for people with disabilities, offered in both inpatient and outpatient settings. For example, a child who is delayed in walking or talking may receive therapy.

The Health Plan Benefits and Coverage Matrix (BCM) is a disclosure that outlines copayments, coinsurance, deductibles and out-of-pocket maximums for covered services. It also includes information related to additional provisions of the benefits offered by Sutter Health Plan.

An HSA (Health Savings Account) is a savings account that allows members to set aside pre-tax money for qualified medical expenses. Using untaxed dollars to pay for deductibles, copayments, coinsurance and other healthcare costs can help lower overall expenses. However, members typically cannot use HSA funds to pay health insurance premiums.

A High-Deductible Health Plan (HDHP) has a higher deductible than traditional health plans but usually has a lower monthly premium. Members pay more out-of-pocket for healthcare costs before the plan begins to cover its share. Members can use their HSA to pay for medical expenses under their HDHP.

Hospital outpatient care is treatment provided at a hospital that typically doesn’t require an overnight stay.

Hospitalization is when an individual is admitted to a hospital as an inpatient, usually requiring an overnight stay. However, an overnight stay for observation may be considered outpatient care.

An individual and family plan is healthcare coverage purchased directly by an individual or family, independent of any employer group or organization.

California defines an employer with 101 or more employees as a large group.

Maternity coverage is an essential health benefit (EHB) that includes inpatient and outpatient medical care for pregnancy, labor and delivery, and newborn care.

A medical group is a group of physicians and other providers who work together to deliver or coordinate covered healthcare services.

Medical services include the professional care physicians and other healthcare professionals provide, such as medical, surgical, diagnostic, therapeutic and preventive services.

Medically necessary services are appropriate and required to diagnose or treat a medical condition, following professionally accepted standards of care.

Medicare is a federal health insurance program for people aged 65 and older, individuals under 65 with specific disabilities and those with end-stage renal disease (e.g., people with permanent kidney failure requiring dialysis or a transplant).

A member is a subscriber or eligible dependent entitled to covered services.

A network includes the facilities, providers and suppliers of a health insurer or plan contracts to deliver healthcare services.

A network provider is a medical group, physician, hospital, or other licensed health professional or facility authorized to practice in California with an active contract with Sutter Health Plan to provide covered services to members at the time of care.

The open enrollment period is the annual timeframe when members can enroll in a health plan. Members may only enroll outside this period if they qualify for a special enrollment period, such as getting married, having a baby or losing other health coverage. Open enrollment periods may vary for employer-based plans.

Out-of-pocket costs are healthcare expenses not reimbursed by a member’s health plan. These include deductibles, coinsurance, copayments for covered services and the full cost of any services not covered.

The OOPM is the maximum amount a member will pay out-of-pocket for most covered services in a single benefit year. It typically includes copayments, coinsurance and deductibles but doesn’t include health plan premiums. Each member has an individual annual OOPM listed in their Benefits and Coverage Matrix (BCM). For families with two or more members, the OOPM is satisfied when a single member reaches their limit or when the combined expenses of all members hit the family maximum.

The Patient Protection and Affordable Care Act refers to any related rules, regulations or guidance issued under it.

Prior authorization — also called preauthorization, prior approval or precertification — is a health plan's decision that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. Health plans may require prior authorization for certain services before they’re provided, except in emergencies. However, prior authorization doesn’t guarantee that the health plan will cover the cost.

A premium is the monthly amount a member pays for healthcare coverage. For employer-based plans, the employer typically covers part of the premium while the member pays the remaining amount, often through payroll deductions.

Preventive care includes routine healthcare such as screenings, check-ups and counseling to prevent or detect illness, disease or other health issues early.

Preventive care services do one or more of the following:

• Detect disease in its earliest stages before noticeable symptoms develop, such as a mammogram to screen for breast cancer
• Promote health, such as counseling on tobacco use
• Protect against disease, such as in the use of immunizations

A PCP directly provides or coordinates a range of healthcare services for a member, including referring a member to specialists for additional services.

A provider is a person or facility that delivers healthcare services, such as doctors, nurses, chiropractors, physician assistants, hospitals, surgical centers and skilled nursing facilities.

The rate guarantee period is when a health plan guarantees that a new member’s monthly premiums won’t increase. However, not all plans include a rate guarantee period.

A referral is when a member’s primary care provider (PCP) approves a visit to a specialist or authorizes specific medical services to diagnose or treat a condition.

Rehabilitation services help individuals keep, regain or improve daily living skills lost or affected by illness, injury or disability. These services may include physical therapy, occupational therapy, speech therapy and psychiatric rehabilitation. Providers offer care in both inpatient and outpatient settings.

A service area is the geographic region where a health plan operates, which may include specific ZIP codes within certain counties. It can determine enrollment eligibility based on where people live or work. Typically, it’s also the area where members receive routine (non-emergency) care.

California defines a small group employer as having at least one, but no more than 100 employee(s).

A specialist is a doctor who focuses on a specific medical field and provides care beyond what a primary care physician (PCP) offers.

A subscriber is someone eligible for health plan coverage on their behalf, not as a dependent, and who meets the plan's subscriber requirements.

The Summary of Benefits and Coverage (SBC) outlines a health plan’s costs and coverage. It also helps people compare health plans based on price, benefits and other important features. Members receive the SBC when shopping for coverage independently or through an employer, renewing or changing plans, or requesting coverage from the health plan.

Urgent care includes medically necessary services for conditions that need prompt attention but aren’t emergencies.