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Glossary

A

Accreditation

The evaluation of a health plan (for example, HMSA’s Health Plan Hawaii or Preferred Provider Plan), health care facility, or program by a third-party organization to ensure that specific standards are met. If the plan, facility, or program meets those standards, it’s assigned an accreditation status.

Actual charge

The amount a provider bills the patient for medical services or supplies.

Administrative review

An approval process that an HMO member’s PCP or other health center provider must request before services are rendered by in-state nonparticipating providers and all out-of-state providers if no HMSA participating providers are available for the services needed. Without prior authorization through this process, services provided by nonparticipating or out-of-state providers won’t be eligible for benefits.

Advance directive

A legal document that tells your health care provider what kind of care you want or don’t want if your medical condition prevents you from making or communicating your decisions (for example, if you’re in a coma).

Alternative therapy

Healing techniques that use options other then conventional medicine. For example, alternative therapies to quit smoking could include hypnosis and laser therapy.

Annual copayment maximum

The maximum deductible and copayment amounts you pay for most covered services in one calendar year.

Annual deductible

The fixed dollar amount you pay each calendar year before your health plan will pay for certain services.

Appeal

Process available to providers and members to ask that a claim or precertification decision be reconsidered.


B

Behavioral health

The management or treatment of stress, depression, substance abuse, and other behavior issues that affect an individual’s well-being.

BlueCard® provider

A provider who participates with the Blue Cross and Blue Shield Association (BCBSA). HMSA is an independent licensee of the Blue Cross and Blue Shield Association.


C

Calendar year

The period starting January 1 and ending December 31 of any year. Your first calendar year for a health plan begins on your effective date and ends on December 31 of that same year.

Centers for Disease Control and Prevention

Agency of the U.S. Department of Health and Human Services that develops and conducts activities for disease prevention and control, environmental health, occupational safety and health, and health education.

Chronic condition

An illness lasting three or more months, as defined by the U.S. National Center for Health Statistics.

Chronic obstructive pulmonary disease

Permanent lung damage, often caused by smoking, in which airflow is blocked and causes wheezing, coughing, and difficulty breathing.

COBRA

Consolidated Omnibus Budget Reconciliation Act of 1986. A federal law that entitles you and your eligible dependents of your employer-sponsored group plan to pay for continued coverage for a specified period if your coverage ends due to a qualifying event such as reduced work hours, loss of employment, or a change in family status.

Confidential Member Information (CMI)

Information about you and the services that you received from a provider, such as your symptoms, exam, test results, injury or illness, treatment, and prescriptions. For more information about your privacy and rights, our duties, and how CMI is used, see the Notice to HMSA Members.

Coordination of benefits

If you’re covered under more than one health plan (for example, a group plan under your employer and as a dependent on your spouse’s plan), HMSA will coordinate benefits for you. This means we’ll apply rules to determine which plan pays first and which pays second.

Copayment

The amount you pay to help share the costs of the health care services or supplies you receive. The copayment is either a fixed percentage of the eligible charge or a fixed dollar amount and applies to most covered services.

Cost share

Also known as Other Brand Name Cost Share. When you share in the cost of Other Brand Name drugs or devices, the amount you pay is called the cost share. You pay the cost share in addition to a copayment.

Coverage

The benefits that are provided according to the specific terms of your health plan.

Covered services

Health care services and supplies that meet HMSA’s payment determination criteria and are described as covered in your Guide to Benefits.

CVS Caremark

A pharmacy benefit service provider contracted by HMSA to process drug claims and administer HMSA’s mail-order drug benefits.


D

Deductible

The dollar amount that you must pay for health expenses before your plan begins paying benefits.

Dependent

A person eligible for coverage under a group plan because of that person’s relationship to the subscriber. Spouses and children are usually eligible for dependent coverage.

Disease management

A program for patients who have or are at risk for a specific chronic condition. Patients receive educational information and communication with health professionals to help manage their condition. This preventive approach decreases patients’ need for medical care and helps to improve their quality of life.

Durable medical equipment

Items that serve a medical purpose and can withstand repeated use, such as wheelchairs, walkers and crutches.


E

Eligible charge

The lower of the participating provider’s actual charge or the amount that HMSA establishes as the maximum allowable fee. This is the amount on which your copayment is based.

Employee Retirement Income Security Act

The Employee Retirement Income Security Act, or ERISA, is a federal law passed in 1974 that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.

Employer-sponsored group plan

An employee benefit plan established or maintained by an employer or by an employee organization (as that term is defined by ERISA), or both, that provides medical care to employees and their dependents directly or through insurance, reimbursement or otherwise.


F

Formulary

A list of drugs that are covered under your drug plan.


G

Generic drugs

Prescription drugs that have the same active ingredient as brand-name drugs. They’re prescribed or dispensed under their formula or chemical names, which aren’t protected by patent. According to the Food and Drug Administration, generic drugs are as safe and effective as brand-name drugs, and generic drugs typically cost less.

Gestational diabetes

A form of diabetes that appears during pregnancy (gestation) in a woman who previously didn’t have diabetes. Gestational diabetes is treatable, especially if detected early in pregnancy.


H

Health center

A specified group of providers in the Health Plan Hawaii network that you designate as your primary center of care. Your designated health center is made up of your PCP and other providers.

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act of 1996 is a law with several components. Title I addresses health care portability to protect health insurance coverage for workers and their families when they change or lose their jobs. Title II is designed to reduce the administrative costs of providing and paying for health-care through standardization. It includes requirements to protect the privacy of individuals’ health information.

Health maintenance organization (HMO)

A health care system used by plans such as HMSA’s Health Plan Hawaii. HMO plans provide coverage for a wide variety of health care services with an emphasis on preventive care. As an HMO member, you select a PCP and health center from the plan’s network. All care you receive must be provided or arranged by your PCP except for emergency care, HMSA’s Online Care, vision exams, gynecological exams, and mental health and substance abuse treatment.

High Density Lipoprotein

HDLs transport cholesterol from the body tissues to the liver, so the cholesterol can be eliminated. HDL cholesterol is considered the “good” cholesterol. The higher the HDL cholesterol level, the lower the risk of coronary artery disease.

HMO home plan

Your HMSA group or individual HMO health care plan. Your HMSA plan is the home plan when you are enrolled in the Guest Membership program. HMSA works with the HMO host plan to administer benefits while you’re away from home.

HMO host plan

A health care plan on the Mainland that provides you with a guest membership. The host plan participates in the Blue Cross Blue Shield Away From Home Care program and works with HMSA (your HMO home plan) to administer benefits while you’re away from home.


I

Immunization

The introduction of a vaccine or serum into a living organism to stimulate the immune system, the body’s natural disease-fighting system, to recognize invading bacteria and viruses and to produce substances (antibodies) to destroy or disable them.

Influenza

A virus infection of the upper respiratory system. Most people who get the flu recover completely in one to two weeks. However, some people develop serious and potentially life-threatening medical complications. An annual influenza immunization can help you avoid getting the flu.

Inpatient

A patient who has been admitted to a hospital or other medical facility for evaluation, treatment and observation, and requires an overnight stay.


L

Lifetime maximum

The maximum benefit amount set by HMSA that each member is eligible to receive during their lifetime.


M

Managed care

Organized system of health care delivery that manages cost efficiency, health care quality, and provider accessibility. Common managed care plans are the health maintenance organization (HMO) and the preferred provider organization (PPO).

Maximum allowable fee

The maximum amount that HMSA will pay for covered services and supplies.

My Account

A secure area on HMSA’s website, that helps you manage your membership with HMSA. My Account allows you to access information about your own plan and claims, download HMSA forms, and use helpful tools.


N

National Committee for Quality Assurance

An independent, not-for-profit organization that evaluates how well a managed care organization meets quality standards. Its accreditation process is nationally recognized for improving health care access and quality.

Network

Also called provider network. A group of physicians, hospitals, and other health-care professionals who are under contract with HMSA. HMSA negotiates payment rates with the network to provide services to its members.

Nicotine replacement therapy

The use of nicotine patches, nicotine gum, and other nicotine products as part of a smoking-cessation program.

Nonparticipating provider

A provider who is not under contract with HMSA.

When you receive services from a nonparticipating provider, you owe a copayment plus the difference between the actual charge on the nonparticipating provider’s claim and HMSA’s eligible charge. If you receive services from a participating provider you do not owe the difference between the provider’s actual charge and the eligible charge and your out-of-pocket expense will be less.


O

Open enrollment period

The specific days each year during which you can make changes to your health plan coverage for the next plan year.

Outpatient

A patient who receives health care services without overnight admission to a hospital or other medical facility. Outpatient care may be provided in a physician’s office, a clinic, the patient’s home, or an emergency room.


P

Participating provider

A physician, hospital, pharmacy, laboratory, or other health care provider that has a contract with HMSA to render services to members at a prenegotiated fee. HMSA’s participating providers obtain precertification for services and medical supplies, limit or adjust their charges to a specified amount, collect members’ copayments, and file claims for members.

Payment determination criteria

Criteria HMSA is required by Hawaii law to use to determine if a service or supply is medically necessary.

Pneumococcal

Related to a bacterium of the genus Streptococcus (S. pneumoniae) that causes the most common and severe forms of pneumonia, an infection of one or both lungs.

Postpartum depression

Also called postnatal depression, a type of depression that affects 10 percent of women who give birth or have a miscarriage. It may interfere with the mother’s ability to care for her baby and handle other daily tasks.

Precertification

Approval process used before certain services and supplies are rendered to ensure that the services or supplies are covered services.

Preferred brand drug

A brand drug that has a preferred brand status on an HMSA prescription drug formulary. You may incur a higher copayment for a preferred drug than a generic drug.

Preferred provider organization (PPO)

A type of health plan that allows you to choose any health care provider.

Providers within the network agree to accept HMSA’s eligible charge, minus your copayment, as payment in full. Nonparticipating providers haven’t agreed to accept HMSA’s eligible charge as payment in full. If you receive services from a nonparticipating provider, you owe a copayment plus the difference between the nonparticipating provider’s billed charge and HMSA’s eligible charge.

Premium

Also known as dues, it’s the amount you or your employer pay to belong to a health plan.

Prepaid credit card

You can use this stored-value card to make purchases or get cash you have deposited into the card’s account. Since the card is endorsed by a credit card company, you can use it anywhere credit cards may be used. Also, there’s no interest charges because you aren’t borrowing money from a financial institution.

Preventive care

Services for early detection and treatment of diseases. It also includes programs that promote healthful lifestyles through immunizations, workshops, counseling, and education.

Primary care

General medical care that focuses on preventive care and the treatment of routine injuries and illnesses.

Primary care provider

As an HMO member, you choose a personal care provider within your selected health center to act as your personal health care manager who coordinates your care.


Q

Qualifying event

An occurrence (for example: death, termination of employment, or change in family status, such as divorce) that changes a former employee’s eligibility status under a group health plan. The term is used in reference to COBRA eligibility.


R

Referral

In some health plans, such as an HMO, if the PCP determines that a patient’s condition requires the services of a specialist or facility, the PCP arranges for the patient to receive the necessary care from the appropriate provider to ensure the services are covered.

Refractive eye surgery

Corrective laser eye surgery. This includes reshaping the cornea with a laser (PRK or LASEK) or reshaping the cornea with an incision and a laser (LASIK®).

Report to Member

A narrative or claim determination (payment or denial) that’s sent to the subscriber or specific dependent of an HMSA account when a claim is processed. The Report to Member may also be known as an Explanation of Benefits.


S

Screening

Testing for early detection of a specific disease in individuals without signs or symptoms of the disease.

Secure message

A private way for you to send and receive messages that prevents messages from being intercepted by someone other than the intended recipient. Secure messages help protect information such as confidential member information.

Security code

A feature for credit or debit card transactions that gives increased protection from fraud. On MasterCard, Visa, and Discover credit or debit cards, it typically consists of three digits printed on the back of the card, to the right of the signature strip. On American Express cards, it is four digits printed on the front of the card, on the right side.

Single-source generic drug

A single-source generic drug is a generic drug that is more expensive than other generics because only one manufacturer makes it.

Skilled nursing facility (SNF)

A licensed facility that provides inpatient nursing care and rehabilitation services for patients who don’t require hospitalization for an acute condition. At an SNF, an on-call physician and registered nurse are available 24 hours a day.

Specialist

A provider who is specifically trained in a certain branch of medicine related to a service or procedure, body area or function, or disease.

Subscriber

The person who fills out the enrollment form and is covered by an individual plan or an employer’s group insurance policy or health plan. If the plan allows family coverage, the subscriber (policy holder) may also enroll eligible dependents in the plan.


U

Urgent care

Medical care for an unexpected illness or injury that isn’t life-threatening but can’t wait until the patient visits a PCP.


W

Well-woman exam

A gynecological examination that typically includes a pelvic exam, a collection of a specimen for Pap smear screening, and a clinical breast exam.