Allowed amount: The maximum amount on which payment is based for covered health care services. This may be called “allowable charge”, “eligible expense,” “payment allowance,” or “negotiated rate.”
Appeals and grievances: This is a written or verbal expression of dissatisfaction about Anthem Blue Cross, Anthem Blue Cross providers, or an Anthem Blue Cross vendor.
Balance billing: A bill for the difference between the amount the plan reimburses for covered services — the allowable amount — and what an out-of-network provider chooses to charge. You are not required to pay this amount if you see an in-network provider.
Benefit year: The benefit year is the 12-month period during which expenses accumulate toward your deductible and out-of-pocket maximum. For the UC Residents & Fellows plans, the benefit year runs from 12:01 a.m. on July 1 to 11:59 p.m. on June 30 of the following year. When the benefit year resets, so do your deductible and out-of-pocket maximum.
Benefit-year deductible: The amount you pay out of pocket for health care before the plan begins to share in the cost of covered services. There are separate deductibles for in- and out-of-network care. What you pay for one doesn’t count toward the other.
Prescription drug expenses are combined with the medical deductible so that what you pay for prescriptions counts toward the medical deductible.
Brand-name drugs: FDA-approved drugs under patent to the original manufacturer and available only under the original manufacturer’s brand name.
Calendar-year maximum: This is the maximum amount the dental plan will pay for covered services during the calendar year.
Claim: A provider’s request to Anthem Blue Cross asking to be paid for a service you’ve received. Visit Plan Documents and Forms to learn more.
Coinsurance: The percentage you pay for the cost of covered health care services after you meet your benefit-year deductible.
Copayment: A set dollar amount you pay for doctor visits, prescriptions and other covered health care services when you see in-network providers. To find an in-network provider near you, visit anthem.com/ca. (Some services are not available.)
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.
Eligibility: The benefits package available to you depends on the type of job you have, the percentage of time you work, and the length of your appointment. Visit New Residents and Fellows for more details.
Emergency medical condition: An illness, injury, symptom or condition so serious that you would seek care right away to avoid severe harm.
Emergency or authorized transport: Ambulance services for an emergency medical condition.
Emergency room care: Emergency services you get in an emergency room.
Excluded services: Health care services that your health insurance doesn’t pay for or cover.
Explanation of Benefits: After you get care, you’ll receive an Explanation of Benefits (EOB) statement from Anthem Blue Cross, the claims administrator. The EOB provides information about how your claim was paid, including how much you owe or will be reimbursed.
Formulary: A list of drugs determined and maintained by Anthem to use for its prescription drug program. The formulary is designed to assist physicians in prescribing drugs that are medically necessary and cost effective. The formulary structure features generic medications (with the lowest copayments) and preferred and non-preferred brand-name drugs. It is updated periodically. If not otherwise excluded, all generic drugs are included on the formulary.
Generic drugs: Approved by the FDA as pharmaceutically equivalent to their brand-name version. Drugs listed as generic have the same active ingredient as their brand-name versions but at a lower cost.
Health insurance: A contract that requires your health insurer to pay some or all of your covered health care costs in exchange for a premium.
HMO (health maintenance organization): A managed care approach to health care that requires that a primary care physician (PCP) coordinate all of your care. Typically, except for emergencies, no care is covered outside the HMO. However, with the UC plan, you also have the option to go to UC health center doctors and hospitals.
Home health care: Health care services a person receives at home.
Hospice services: Services provided to support end-of-life care when the patient’s condition is terminal and he or she can no longer receive curative treatment. Support services are also provided to the patient’s family members.
Hospital outpatient care: Care in a hospital that usually doesn’t require an overnight stay.
Hospitalization: Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
In-network copayment: Available only when you see a provider in the Anthem Preferred network or a UC health center. This is a fixed amount (for example, $20) that you pay for covered health care services. To find an Anthem Preferred provider near you, visit anthem.com/ca.
Inpatient: An individual who has been admitted to a hospital as a registered bed patient and is receiving services under the direction of a physician.
Maintenance medications: Prescribed to treat chronic health conditions — such as asthma, diabetes, high blood pressure, or high cholesterol — and are taken on an ongoing, regular basis to maintain health.
Medically necessary: Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine.
Network: The facilities, providers and suppliers your health plan has contracted with to provide covered health care services.
Network providers: State-licensed health care providers who have contracted with a health care plan and have agreed to certain rates. In most cases, you pay less and receive a higher level of benefits when you use in-network providers (UC health center or Anthem Preferred). Check your plan for coverage details.
Non-preferred drugs: Drugs listed as “non-preferred” generally have higher copayments than preferred brand-name drugs.
Out-of-network coinsurance: The percentage (for example, 50%) you pay of the allowable amount for covered health care services to providers who do not contract with your health plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
Out-of-network providers: Providers who are not in the Anthem Preferred network or not affiliated with a UC health center, or who have not contracted with Anthem Blue Cross and have not agreed to charge certain rates.
Out-of-pocket maximum: The most you’ll pay for covered health care services in a benefit year. Once you reach it, the plan pays 100% of the costs for covered services.
There are separate out-of-pocket maximums for in- and out-of-network care. What you pay for one doesn’t count toward the other.
Prescription drug expenses are combined with the medical out-of-pocket maximums so that what you pay for prescriptions counts toward the medical out-of-pocket maximum.
Outpatient: An individual receiving health care services, but not as an inpatient.
Preauthorization: A decision by your health plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called “prior authorization,” “prior approval” or “precertification.” Your health plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health plan will cover the cost.
Preferred provider organization (PPO): A PPO is similar to a traditional “fee-for-service” plan, but you must use doctors in the PPO provider network or pay a higher coinsurance (percentage of charges). A PPO allows you to select most providers without a referral. In these plans, you typically must meet an annual deductible before some benefits apply. You are responsible for a certain coinsurance amount, and the plan pays the balance up to the allowable amount. As a PPO health plan member, you get maximum benefit coverage when you use the PPO network of physicians and hospitals.
Premium: Your health care costs begin with your premium — the amount that’s deducted from your paycheck for your coverage. Learn more about your costs.
Prescription drugs: Drugs and medications that by law require a prescription.
Preventive care: You have access to preventive services through your medical plan at no cost to you if a participating provider is used and the claims they submit are coded correctly. The types of preventive services covered generally must have been rated as an A or B service by the U.S. Preventive Services Task Force, although the medical plan you are enrolled in may cover additional preventive services that did not receive this rating. Follow-up testing for a diagnosed medical condition (such as additional glucose or cholesterol level tests) generally won’t be covered as preventive. The following preventive services are covered for men, women and children:
- Annual well-adult and well-woman exams
- Well-baby and well-child visits based on the American Academy of Pediatrics and the American Academy of Family Physicians age and frequency guidelines
- Blood pressure, diabetes and cholesterol tests based on age and gender guidelines
- Routine mammograms and cervical cancer screening, including PAP tests
- Colorectal cancer screenings, including fecal occult blood testing, sigmoidoscopy or colonoscopy, based on age guidelines
- Counseling on topics such as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use
- Routine vaccinations against diseases such as measles, polio and meningitis
- Flu and pneumonia shots
- Counseling, screening and vaccines to ensure healthy pregnancies
- Women’s preventive services
- Breast feeding support, supplies and counseling, including breast pumps
- Contraception counseling
- Contraception methods (IUDs and diaphragms)
- Domestic violence screening
- Gestational diabetes screening
- HIV screening and counseling
- Human papillomavirus testing (beginning at age 30, and every three years thereafter)
- Sexually transmitted infections and counseling
Primary care physician: A physician (an M.D. — Medical Doctor or a D.O. — Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary care provider: A physician (an M.D. — Medical Doctor or a D.O. — Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Provider: A physician (an M.D. — Medical Doctor or a D.O. — Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Rehabilitation services: Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because the person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Services: Includes medically necessary health care services and medically necessary supplies furnished incident to those services.
Skilled nursing care: Services provided by licensed nurses in your own home or in a skilled nursing facility. Skilled care services are provided by licensed technicians and therapists in your own home or in a nursing facility.
Specialist: A physician specialist who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Specialty medications: Drugs that are used to treat complex or chronic conditions that usually require close monitoring, such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancer and other conditions that are difficult to treat with traditional therapies. Specialty drugs may be self-administered in the home by injection (under the skin or into a muscle), by inhalation, by mouth or on the skin. These drugs may also require special handling and/or special manufacturing processes, and they may have limited prescribing or limited pharmacy availability. Specialty drugs are obtained from the Anthem specialty pharmacy, Lumicera, and may require prior authorization.
Step therapy program: Step therapy requires members to try preferred medications as the initial step in treatment before select non-preferred medications are covered. Preferred medications included in the program are widely recognized as clinically safe and effective. This program can lower both plan and member costs, while still providing access to non-preferred medications.
Urgent care: Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.