Health Insurance Glossary

A

Acute Care: A pattern of health care in which a patient is treated for an immediate and severe episode of illness, delivery of a baby, for the subsequent treatment of injuries related to an accident or other trauma or during recovery from surgery. Acute care is usually provided in a hospital and is often necessary for only a short period of time. Acute care includes emergency and urgent care.

Advanced Premium Tax Credit (APTC): A tax credit designed to help pay for your monthly premium, when you take it in advance. Or you can wait and take the tax credit at the end of the year when you file your taxes. Whether or not you qualify for this financial help depends on factors including your family size and estimated annual household income for the year the insurance will be in effect. If your actual income does not match your estimate, you may owe or be owed money on your tax return.

Adverse Determination: A denial of a pre authorization for a covered benefit; a denial of benefits based on the grounds that the treatment or covered benefit is not medically necessary, appropriate, effective or efficient or is not provided in or at the appropriate health care setting or level of care; a rescission or cancellation of coverage that is not attributable to failure to pay premiums and that is applied retroactively; a denial of benefits on the grounds that the treatment or service is experimental or investigational; or a denial of coverage based on initial eligibility determination.

Aggregate Deductible: A deductible is the amount you have to pay for allowable covered expenses under a health plan during a specified time period (e.g., a plan year or benefit year) before the plan will begin paying for covered expenses. In an aggregate deductible plan, cost sharing will begin after an individual family member or combination of family members reaches the family deductible amount. The family members then pay copayments and/or coinsurance where applicable for the remainder of the plan year, or until the family out of pocket maximum is met. Once a family member or combination of family members reaches the family out of pocket maximum, then the plan will pay 100% of covered services for the remainder of the plan year.

Ambulatory Surgical Facility: A facility, licensed and operated according to law, which does not provide services or accommodations for a patient to stay overnight. The facility must have an organized medical staff of physicians; maintain permanent facilities equipped and operated primarily for the purpose of performing surgical procedures, and supply registered professional nursing services whenever a patient is in the facility.

Appeal: A written request to change a previous decision made by Denver Health Medical Plan.

Approved Clinical Trial: A phase I, phase II, phase III or phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition and is described in any of the following subparagraphs:

• Federally Funded Trials - The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
  • The National Institutes of Health
  • The Centers for Disease Control and Prevention
  • The Agency for Health Care Research and Quality
  • The Centers for Medicare & Medicaid Services
  • Cooperative group or center of any of the entities described in clauses (i) through (iv) or the Department of Defense or the Department of Veterans Affairs
  • A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants
  • Any of the following if certain conditions are met:
    • The Department of Veterans Affairs
    • The Department of Defense
    • The Department of Energy
• The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration.
• The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

B

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Brand Name Drug: A drug that is identified by its trade name given by the manufacturer. Brand name drugs may have generic substitutes that are chemically the same.

C

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Calendar Year: The 12-month period beginning at 12:01 a.m. on the 1st day of January and ending at 11:59 p.m. on the last day of December.

Chronic Care: A pattern of care that focuses on individuals with long-standing, persistent diseases or conditions. It includes care specific to the problems, as well as other measures to encourage self-care, promote health and prevent loss of function.

Coinsurance: The charge, stated as a percentage of eligible expenses, that you are required to pay for certain covered health services after applicable deductibles are met. This amount will apply to your out-of-pocket maximum.

Complications of Pregnancy:

• Conditions (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; or
• Non-elective cesarean section; ectopic pregnancy, which is terminated; and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

Copayment: A copayment (or copay) is a predetermined amount, sometimes stated as a percentage and sometimes stated as a fixed dollar amount, that you are required to pay to receive a covered service. Copayments are paid directly by you to the provider. For applicable copayments, see the Schedule of Benefits table at the beginning of your handbook. You are responsible for all expenses incurred for non-covered services.

Cosmetic Procedure/Surgery: An elective procedure performed only to preserve or improve physical appearance rather than to restore an anatomical function of the body lost or impaired due to an illness or injury.

Covered Benefit: A medically necessary service, item or supply that is specifically described as a benefit in this handbook. While a covered benefit must be medically necessary, not every medically necessary service is a covered benefit.

Custodial Care: Services and supplies furnished primarily to assist an individual in the activities of daily living. Activities of daily living include such things as bathing, feeding, administration of oral medicines or other services that can be provided by persons without the training of a health care provider.

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Deductible: The amount you owe for medical services before your health insurance plan pays. You will pay the full deductible amount toward medical expenses before your health plan pays anything. In an HDHP the deductible will also apply to pharmacy costs. Once you meet the applicable deductible, your plan will start to cover your expenses based on your list of benefits. 

Denver Health and Hospital Authority (DHHA): A political subdivision of the State of Colorado organized for the primary purpose of providing comprehensive public health and medical health care services to the citizens of the City and County of Denver. DHMP is a separate legal entity from the Denver Health Hospital Authority.

Designated Personal Representative (DPR): A person, including the treating health care professional, authorized by a member to provide substituted consent to act on the member’s behalf.

Domestic Partner: An adult of the same gender with whom the employee is in an exclusive committed relationship, who is not related to the employee and who shares basic living expenses with the intent for the relationship to last indefinitely. A domestic partner cannot be related by blood to a degree that would prevent marriage in Colorado and cannot be married to another person.

Drug and Alcohol Use–Detoxification: The medical treatment of an individual to ensure the removal of one or more toxic substances from the body. Detoxification may or may not be followed by a complete rehabilitation program for drug or alcohol use.

Drug and Alcohol Use–Rehabilitation: The restoration of an individual to normal or near-normal function following addiction. This may be accomplished on an inpatient or outpatient basis.

Durable Medical Equipment: Medical equipment that can withstand repeated use, is not consumable or disposable, except as needed for the effective use of covered durable medical equipment, and is used to serve a medical purpose in the treatment of an active illness or injury. Durable medical equipment is owned or rented to facilitate treatment and/or rehabilitation.

E

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Embedded Deductible: A deductible is the amount you have to pay for allowable covered expenses under a health plan during a specified time period (e.g., a plan year or benefit year) before the plan will begin paying for covered expenses. In an embedded deductible plan, cost sharing for a member will begin when that member reaches their individual deductible, or when a combination of members reaches the family deductible. This means that a member will start to pay copays and/or coinsurance for the remainder of the plan year or until the individual out of pocket maximum is met. Once the individual reaches their out of pocket maximum, then the plan will pay 100% of covered services for that member for the remainder of the plan year. *Please note: an individual who meets their individual deductible will initiate cost sharing with the plan prior to other members on the plan.

Emergency: Any event that a prudent layperson would believe threatens his/her life or limb in such a manner that a need for immediate medical care is needed to prevent death or serious impairment of health.

Emergency Care: Services delivered by an emergency care facility that are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent layperson having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life- or limb-threatening emergency existed.

Experimental or Investigational Service(s): Not yet proven to be, or not yet approved by a regulatory agency, as a medically effective treatment or procedure.

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Family Deductible: The maximum deductible amount that is required to be met for all family members covered under a policy, which may be an aggregated amount (e.g., “$3,000 per family”) or specified as the number of individual deductibles that must be met (e.g., “three deductibles per family”).

Flexible Spending Account (FSA): A Flexible Spending Account (also known as a flexible spending arrangement) is a special account you put money into that you use to pay for certain out-of-pocket health care costs. You don’t pay taxes on this money. This means you’ll save an amount equal to the taxes you would have paid on the money you set aside. Employers may make contributions to your FSA, but aren’t required to.

Follow-Up Care: Care received following initial treatment of an illness or injury.

G

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General Hospital: A health institution planned, organized, operated and maintained to offer facilities, beds and services over a continuous period exceeding 24 hours to individuals requiring diagnosis and treatment for illness, injury, deformity, abnormality or pregnancy. Clinical laboratory, diagnostic X-ray and definitive medical treatment under an organized medical staff are provided within the institution. Treatment facilities for emergency and surgical services are provided either within the institution or by contractual agreement for those services with another licensed hospital. Definitive medical treatment may include obstetrics, pediatrics, psychiatry, physical medicine and rehabilitation, radiation therapy and similar specialized treatment.

Generic Drug: Generic drugs are chemical equivalents of brand-name drugs and are substituted for the brand name drug. When an A-rated generic drug is substituted for a brand name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand name drug.

Genetic Testing: Examination of blood or other tissue for chromosomal and DNA abnormalities and alterations, or other expressions of gene abnormalities that may indicate an increased risk for developing a specific disease or disorder.

Grievance: A written or oral expression of dissatisfaction about the quality of care you receive, the failure of a provider or the Plan to accommodate your needs, an unpleasant experience, disagreement with a claim related issue, such as cost sharing, or any other service issue. This is also called a complaint.

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Habilitative Services: Services that help a person retain, learn or improve skills and functioning for daily living.

Home Health Care/Agency: A program of care that is primarily engaged in providing skilled nursing services and/or other therapeutic services in the home or other places of residence. An approved home health agency:

• Has policies established by a group of professional personnel associated with the agency or organization, including policies to govern which services the agency will provide;
• Maintains medical records of all patients; and
• Is certified or accredited.

Hospice Care: An alternative way of caring for terminally ill individuals that stresses palliative care as opposed to curative or restorative care. Hospice care focuses upon the patient/family as the unit of care. Supportive services are offered to the family before and after the death of the patient. Hospice care is not limited to medical intervention and addresses the physical, social, psychological and spiritual needs of the patient. Hospice services include, but are not necessarily limited to, the following: nursing, physician, certified nurse aide, nursing services delegated to other assistants, homemaker, physical therapy, pastoral, counseling, trained volunteer and social services. The emphasis of the hospice program is on keeping the hospice patient at home among family and friends as much as possible.

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Illness: Any bodily sickness, disease or mental/nervous disorder. For the purposes of this plan, pregnancy and childbirth are considered the same as any other sickness, injury, disease or condition.

Individual Deductible: The deductible amount you and each individual covered by the policy will have to pay for allowable covered expenses before the carrier will cover those expenses.

Injury: A condition that results independently of an illness and all other causes, and is a result of an external force or accident.

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Maintenance Care: Services and supplies that are provided solely to maintain a level of physical or mental function and from which no significant practical improvement can be expected.

Medically Necessary (Medical Necessity): A service or supply that is consistent with generally accepted principles of professional medical practice, as determined by whether: 

1. the service is the most appropriate and available supply or level of service for the insured in question, considering potential benefits and harms to the individual; 
2. the service is known to be effective, based on scientific evidence, professional standards, and expert opinion, in improving health outcomes; and/or 
3. services and interventions not in widespread use are based on scientific evidence.

Medicare: The Federal Health Insurance for the Aged and Disabled Act, Title XVIII of the United States Social Security Act.

Member: A subscriber or dependent enrolled in DHMP and for whom the monthly premium is paid to DHMP.

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Network: Refers to a specified group of physicians, hospitals, medical clinics and other health care providers that your plan may require you to use in order for you to get any coverage at all under the plan, or that the plan may encourage you to use because it may pay more of your bill if you use their network providers (i.e., go in-network) than if you do not (i.e., go out-of-network).

Network Provider: A health care provider who is contracted to be a provider in your specific plan network.

Nurse/Licensed Nurse/Registered Nurse: A person holding a license to practice as a Registered Nurse (R.N.), Licensed Vocational Nurse (L.V.N.) or Licensed Practical Nurse (L.P.N.) in the state of Colorado and acting within the scope of his/her license.

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Observation Stay: A hospitalization lasting 23 hours or less.

Office Visit: Visit with a health care provider that takes place in the office of that health care provider. Does not include care provided in an emergency room, ambulatory surgery suite or ancillary departments (laboratory and X-ray).

Out-of-Pocket Maximum: The most you pay out during a policy period (one plan year) before your health insurance plan pays 100% for your covered health insurance benefits. This limit includes the total of your deductible, coinsurance and copays. This does not include your monthly premiums. In an HDHP, the individual out-of-pocket maximum does not apply to a family plan.

P

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Partial Hospitalization/Day Treatment: Defined as continuous treatment at a network facility of at least 3 hours per day but not exceeding 12 hours per day.

Provider: A physician or person acting within the scope of applicable state licensure or certification requirements and possessing the credentials to practice as a Certified Nurse Midwife (C.N.M.), Certified Registered Nurse Anesthetist (C.R.N.A.), Child Health Associate (C.H.A.), Doctor of Osteopathy (D.O.), Doctor of Podiatry Medicine (D.P.M.), Licensed Clinical Social Worker (L.C.S.W.), Medical Doctor (M.D.), Nurse Practitioner (N.P.), Occupational Therapist (O.T.), Physician Assistant (P.A.), Psychologist (Ph.D., Ed.D., Psy.D.), Registered Physical Therapist (R.P.T.), Registered Respiratory Therapist (R.T.), Speech Therapist (S.T.) or any other person who is licensed or otherwise authorized in this state to furnish health care services.

Premium: Monthly charge to a subscriber for medical benefit coverage for the subscriber and his/her eligible and enrolled dependents.

Preventive Visit: Preventive care visits/services are designed to keep you healthy or to prevent illness, and are not intended to treat an existing illness, injury or condition.

Primary Care Practitioner (Personal Provider): The practitioner (physician, nurse practitioner or physician’s assistant) that you choose from your plan network to supervise, coordinate and provide initial and basic care to you. The personal provider initiates referrals for specialist care and maintains continuity of patient care (usually a physician practicing internal medicine, family practice or pediatrics).

Prior Authorization: If approved, provides an assurance by the plan to pay for a medically necessary covered benefit provided by a designated provider for an eligible plan member and is received prior to receiving a specific service, treatment or care. This process can be initiated by a provider, patient or designated patient representative.

Prudent Layperson: A non-expert using good judgment and reason.

Q

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Qualifying Event (For Continuation Coverage): An event (termination of employment, reduction in hours) affecting an individual’s eligibility for coverage.

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Referral: A written request, signed by a member’s personal provider, defining the type, extent and provider for a service.

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Service Area: The geographical area in which a health plan is licensed to sell their products.

Skilled Nursing Care: The care provided when a registered nurse uses knowledge as a professional to execute skills, render judgments and evaluate process and outcomes. A non-professional may have limited skill function delegated by a registered nurse. Teaching, assessment and evaluation skills are some of the many areas of expertise that are classified as skilled services.

Skilled Nursing Facility: A public or private facility, licensed and operated according to the laws of the state in which it provides care that has:

• Permanent and full-time facilities for 10 or more resident patients;
• A full-time registered nurse or physician in charge of patient care;
• At least one registered nurse or licensed practical nurse on duty at all times;
• A daily medical record for each patient;
• Transfer arrangements with a hospital; and
• A utilization review plan.

Specialized Treatment Facility: Specialized treatment facilities for the purposes of this plan include ambulatory surgical facilities, hospice facilities, skilled nursing facilities, mental health treatment facilities, substance abuse treatment facilities or renal dialysis facilities. The facility must have a physician on staff or on call. The facility must also prepare and maintain a written plan of treatment for each patient.

Standing Referral: Referral from your primary care provider to a network specialist or specialty treatment center in the DHMP network for illness or injury that requires ongoing care.

Subrogation: The recovery by Denver Health Medical Plan of costs for benefits paid by Denver Health Medical Plan when a third party causes an injury and is found liable for payment of damages.

Subscriber: The head of household and the basis for eligibility for enrollment in DHMP.

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Telehealth: A mode of delivery of health care services through telecommunications systems, including information, electronic and communication technologies, to facilitate the assessment, diagnosis, consultation, treatment, education, care management or self-management of a covered person’s health care while the covered person is located at an originating site and the provider is located at a distant site. The term includes synchronous interactions and store-and-forward transfers.

• Distant Site: A site at which a provider is located while providing health care services by means of telehealth.
• Originating Site: A site at which a patient is located at the time health care services are provided to him/her by means of telehealth.
• Store-and-Forward Transfer: The electronic transfer of a patient’s medical information or an interaction between providers that occurs between an originating site and distant sites when the patient is not present.
• Synchronous Interaction: A real-time interaction between a patient located at the originating site and a provider located at a distant site.

Temporarily Absent: Circumstances in which the member has left DHMP’s service area, but intends to return within a reasonable period of time, such as a vacation trip.

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Urgent Care / Urgently Needed Services: Covered services that members require in order to treat and prevent a serious deterioration in their health, but which do not rise to the level of an emergency.

USPSTF: The U.S. Preventive Services Task Force or any successor organization, sponsored by the Agency for Healthcare Research and Quality, the Health Services Research Arm of the federal Department of Health and Human Services.

U.S. Preventive Services Task Force (USPSTF) A Recommendation: A recommendation adopted by the Task Force that strongly recommends that clinicians provide a preventive health care service because the Task Force found there is a high certainty that the net benefit of the preventive health care service is substantial.

U.S. Preventive Services Task Force (USPSTF) B Recommendation: A recommendation adopted by the Task Force that recommends that clinicians provide a preventive health care service because the Task Force found there is a high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Utilization Review: A set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy or efficiency of, health care services, procedures or settings. Techniques include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review. Utilization review shall also include reviews for the purpose of determining coverage based on whether a procedure or treatment is considered experimental or investigational in a given circumstance, and reviews of a covered person’s medical circumstances when necessary to determine if an exclusion applies in a given situation.

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Virtual Residency Therapy: Home-based intensive services for clients and families, which may include comprehensive case management, family therapy, individual therapy, parting skills training, communication skills counseling and case coordination with other services.

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Well-Baby Care: In-hospital newborn pediatric visit and newborn hearing screening. The hospital copayment applies to mother and well-baby together; there are no separate copayments unless mother and baby are discharged separately.