Download Attachment B University System of Georgia (USG) Student Health

Attachment B
University System of Georgia (USG)
Student Health Insurance Program (SHIP) Special Term Definitions
Affordable Care Act (ACA) -- also known as Healthcare Reform: Federal legislation officially entitled the
Patient Protection and Affordable Care Act (PPACA) in the process of definition and implementation through
the Department of Health and Human Services. ACA includes covered benefits, eligibility, and premium rate
mandates with a focus on high volume plan consortia, preventive medicine, wellness benefits, elimination of
pre-existing conditions, and expansion of eligibility and maximum benefit coverage.
Allowable Expense(s) -- also known as Covered Expense(s): Any medically necessary and reasonable
expense, part or all of which is covered under any of the health benefits or health insurance plans of the
insured for which the claim is made.
Ambulatory Surgery: Procedures not requiring an overnight stay in the hospital or ambulatory surgery
center/facility. These procedures can be performed in the hospital, a surgery center or physician office as long
as an overnight stay is not involved.
American College Health Association (ACHA): A non-profit professional association that provides advocacy,
education, communications, products, and services, as well as promoting research and culturally competent
practices, to support college and university health professionals and enhance their ability to advance the health
of all students and the campus community.
Appeals: A process available to the insured to ask that the health plan reconsider a benefit denial or claim
decision.
Authorization: The process of receiving approval for some health care, such as outpatient surgery,
hospitalization, or prescription drugs, before it can be covered. Through this process, eligibility and
determination of coverage can be confirmed and communicated before a member receives treatment or
services.
Benefit: Payment received for covered services under the terms of a health insurance/health benefits plan or
policy. Or the amount payable by an insurer to a person making a claim, assignee or beneficiary under each
coverage in a group contract.
Benefit Period: The maximum length of time for which benefits will be paid.
Certification: The process of receiving approval for some health care, such as outpatient surgery,
hospitalization or prescription drugs, before it can be covered. Through this process, eligibility and
determination of coverage can be confirmed and communicated before the insured receives treatment or
services.
Claim: A request for benefits payment to an insured employee or beneficiary (the claimant).
COBRA: COBRA stands for Consolidated Omnibus Budget Reconciliation Act. It refers to an avenue of
health insurance coverage created as a result of that act as follows: COBRA insurance is a temporary
continuation of a health plan for a worker and/or his family at their own cost. The option is available if certain
events occur that would otherwise result in a loss of those health benefits.
Coinsurance - A form of medical cost sharing in a health insurance plan that requires an
insured person to pay a stated percentage of medical expenses after the deductible
amount, if any, was paid.
Conversion Charge: The amount charged to the policyholder when a covered member chooses to convert
group policy coverage to an individual policy.
Copayment: A form of medical cost sharing in a health insurance plan that requires an
insured person to pay a fixed dollar amount when a medical service is received. The
insurer is responsible for the rest of the reimbursement.
Credentialing: A process to evaluate a doctor, physician assistant, or nurse practitioner qualifications and
record of professional competence and conduct. The process includes a review of related training, academic
background, experience, licensing, certification and/or registration to practice in a health care field.
Deductible: A fixed dollar amount during the benefit period - usually a year - that an
insured person pays before the insurer starts to make payments for covered medical
services. Plans may have both per individual and family deductibles.
Dependent: A person who is eligible to receive life and/or health insurance/health benefits coverage under a
plan's provisions. Examples would be the plan insured’s spouse or child.
Eligibility: Insurance policy terms that defining who is eligible to get coverage and the requirements for
receiving coverage.
Exclusions: Specific conditions or circumstances that are not covered for benefits under a plan.
Experimental or Investigational Treatment, Services, Drugs, Devices, Procedures or Supplies: Those
medical services, treatment, drugs/medications, and supplies not recognized by the medical community and/or
agencies responsible for oversight and approval (e.g. Food and Drug Administration [FDA]/ Institutional
Review Board [IRB] approved Phase III clinical trials, Department of Health and Human Services [HHS]) that
are typically excluded as a health insurance covered benefit.
Explanation of Benefits (EOB): A form that explains how the payment amount for a health benefit/health
insurance claim was calculated. It also may explain the claims appeal process and provide other information,
including contact information.
First Contact Student Health Service (FCSHS): USG Institution Student Health Services that elect to
function as first point of primary care contact for students enrolled in the USG SHIP will be designated as a
First Contact Student Health Service (FCSHS). Deductibles and copays will be waived for programs and
services provided at the student’s USG Institution FCSHS. The USG Insitution FCSHS will be considered a
Primary Care Physician/Provider (PCP) as defined in this Special Term Definition document. As First
Contact PCP all students enrolled in the USG will be required to use their USG Institution FCSHS for
referrals, except for the following conditions:
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Medical emergencies (follow-up treatment requires FCSHS referral);
When the FCSHS is closed;
When treatment is received more than 25 miles from the FCSHS;
The USG SHIP insured person is not eligible for care at the FCSHS; and
The USG SHIP insured person requires treatment for programs or services not provided at the FCHS.
Deductible and copays apply to all exceptions to the FCSHS referral requirement, and when a referral
is obtained – i.e. for treatment/care given by the provider or health care organization the insured
person is referred to.
Formulary Medications: A list of the prescription drugs that are approved for coverage by many of the
pharmacy benefits plans. It includes many brand-name and generic drugs approved by the U.S. Food and Drug
Administration (FDA). Based on an insured member's plan, drugs on the formulary may have lower copay
than non-formulary drugs.
Hard waiver: An insurance enrollment process that requires showing or demonstrating proof that a student is
properly insured. It is the process followed the USG and USG Institutions whereby students in programs
requiring health insurance are automatically enrolled in the SHIP and are then required to show proof of
insurance to “waive” out of the university plan.
HIPPA: HIPPA stands for the Health Information Portability and Privacy Act. It refers to federal guidelines
aimed at protecting patient privacy and confidentiality, including Personal Health Information (PHI)
maintained and/or transmitted in hardcopy or digital/electronic format.
Hospital: An organization providing inpatient and outpatient medical services, which is accredited as a
hospital by the appropriate national organizations (e.g., Joint Commission) or otherwise determined as meeting
reasonable standards. A hospital may be a general, acute care, rehabilitation or specialty institution.
ICD-10 Code: International Statistical Classification of Diseases and Related Health Problems
ID Card: A card given out by a health insurance company that provides information about the coverage. It
typically includes a unique member identification number or numbers (individual and/or group), and a toll-free
phone number to contact the insured customer services.
In-Network: Refers to the use of health care professionals who participate in the health plan's managed care
provider and hospital network.
Inpatient Care: Service provided after a patient is admitted to the hospital. Inpatient care lasts 24 hours or
more.
Mandatory Enrollment: An insurance enrollment process that requires showing or demonstrating proof that
a student is properly insured. It is the process followed by the USG and USG Institutions whereby students in
programs requiring health insurance are automatically enrolled in the SHIP and are then required to show
proof of insurance to “waive” out of the SHIP.
Managed Care Network: A health plan administration feature to help manage cost for the plan and the
insured members through access to a network of contracted health care professionals, hospitals, and other
health care facilities, requiring negotiated fee schedules and approval of some services.
Medically Necessary: Services or supplies that are appropriate for or consistent with the diagnosis according
to accepted medical standards as described in the covered benefits section of the plan. The term applies only to
the determination by the plan whether health care services are covered benefits. All services are subject to the
exclusions and limitations described in the plan documents.
Medical Underwriting or Underwriting (Underwriter): The process of doing an individual and/or group risk
analysis for someone applying for new or increased health insurance coverage. The underwriter(s) is(are) the
professional or professionals responsible for the process.
Nonparticipating Provider (also known as Out-of-Network Provider): Generally used to mean health care
professionals, hospitals, and other health care facilities that have not contracted with a health plan to provide
services at reduced fees.
Offeror: A health insurance company/vendor submitting a proposal in response to the University System of
Georgia Student Health Insurance Program Request for Proposal (RFP).
Out-of-Pocket Maximum: The highest amount a health plan member is required to pay for covered services
outside of his/her benefits plan. Once the member reaches the out-of-pocket maximum(s), the plan pays 100%
of expenses for covered services.
Outpatient Care: Care provided in an ambulatory care center, outpatient service or clinic (including a
university health center), emergency room, hospital or non-hospital surgical center, without admitting the
patient.
Outpatient Surgery or Ambulatory Surgery: Procedures that do not require an overnight stay in the
hospital or ambulatory surgery facility. These procedures can be performed in the hospital, a surgery center or
physician office.
Pharmacy Copay or Pharmacy Copayment: The amount of money a member pays to a participating
pharmacy for prescription drugs covered by a pharmacy benefits plan.
Plan Exclusions and Limitations: Binding terms and conditions that are applied to insurance plans. They
may refer to services, specific types of coverage, pre-existing conditions and/or other limitations.
Preadmission Certification - An authorization for hospital admission given by a health care provider to an
insured member prior to their hospitalization.
Pre-Existing Condition: A health condition (other than pregnancy) or medical problem that was diagnosed
or treated during a specified time before enrollment in a new insurance plan.
Premium: Agreed upon fees paid for coverage of medical benefits for a defined benefit period.
Primary Care Physician/Provider (PCP): A physician, physician assistant, or nurse practitioner who serves
as a group member's primary contact within the health plan. In a managed care plan, the primary care physician
provides basic medical services, coordinates and, if required by the plan, authorizes referrals to specialists and
hospitals.
SAS 70: Statement on Auditing Standards (SAS) No. 70, is a widely recognized auditing standard developed
by the American Institute of Certified Public Accountants (AICPA). A service auditor's examination performed
in accordance with SAS No. 70 (also commonly referred to as a "SAS 70 Audit") is widely recognized, because
it represents that a service organization has been through an in-depth audit of their control objectives and
control activities, which often include controls over information technology and related processes.
http://sas70.com/sas70_overview.html
Second Surgical Opinion: A cost-management strategy that encourages or requires patients to obtain the
opinion of another doctor after a physician has recommended that a non-emergency or elective surgery be
performed.
SHIP: Student Health Insurance Program.
Urgent Care: Services received for an unexpected illness or injury that is not life threatening but requires
immediate outpatient medical care and prompt medical attention to avoid problems and unnecessary or severe
pain, such as a high fever.
USG: University System of Georgia.
Usual, customary, and reasonable (UCR) charges: UCR charges mean that the charge is the provider’s usual
fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the
circumstances.
Well Baby/Well Child Care: The routine care, testing, checkups and shots for a generally healthy child from
birth through the age of eight.
Wellness Coverage or Benefits: Plan benefits focusing on disease prevention, medical self-care and health
promotion.