Commonly used health insurance terms

An Activity Summary, also known as an explanation of benefits or EOB, is a monthly summary that lists the services you received, the amount the provider charged, and the amount Harvard Pilgrim paid or denied. The Activity Summary is not a bill, but it will tell you if you owe your provider money. A new Activity Summary will be posted each month to your online account. We will also mail you an Activity Summary when you are responsible for a deductible, coinsurance or an amount not covered by your plan.

Generally, this is the maximum amount that Harvard Pilgrim will pay a provider for covered services. If you have a POS or a PPO plan and you see a non-participating provider, it’s possible that the provider will charge more than the allowed amount for the care you received. In that case, you would be responsible for paying the difference between the provider’s charges and Harvard Pilgrim’s allowed amount. This is sometimes called “balance billing.” Note: If you have an HMO plan, there is no coverage for care you receive from non-participating providers, except in an emergency.

Ambulatory care or outpatient care is medical care provided on an outpatient basis, such as diagnosis, consultation, treatment, intervention and rehabilitation services.

Balance billing is something that can happen when POS and PPO members see non-participating providers for covered services. Non-participating providers sometimes charge more than Harvard Pilgrim’s allowed amount for the care they provide. After Harvard Pilgrim pays the non-participating provider’s claim, you would be responsible for paying any balance on the provider’s bill over and above what Harvard Pilgrim paid. That amount would not count toward your out-of-pocket maximum. Note: If you have an HMO plan, there is no coverage for care you receive from non-participating providers, except in an emergency.

Learn more about your rights and protections against surprise medical bills.

A claim is a provider’s request to be paid for your care. When providers send claims to Harvard Pilgrim, we will look at your benefits and figure out who needs to pay the provider and how much. If you need to pay, you will receive a bill from the provider, which you should compare against the Activity Summary you receive from Harvard Pilgrim.

This is a fixed percentage of costs that you pay for covered services. For example, if you have a plan with coinsurance, you may have to pay 20% of a provider’s bill for your care, while Harvard Pilgrim pays 80%. Coinsurance is usually something you pay after you have paid an annual deductible.

This is a flat dollar amount you pay for certain services on your plan. You may have different copayments for different services (e.g., primary care visits, specialist visits and prescription drugs). Copayments are normally due when you have your appointment or when you pick up prescriptions from the pharmacy. Your Plan Benefits page will tell you what your copayments are for different services.

Cost sharing is what you pay for specific health care services (e.g., office visits, X-rays and prescriptions). Coinsurance, copayments and deductibles are all examples of cost sharing.

Being covered for something means that it’s part of your benefits package. You still may need to pay copayments, coinsurance or a deductible. If something is “covered in full,” that means there’s no charge to you.

This is a set amount of money that you have to pay out of your own pocket for certain services. If you have a $2,000 annual deductible, for example, you will have to pay $2,000 worth of charges before Harvard Pilgrim helps pay. If you receive care for services that fall under the deductible, your provider will send you a bill. If prescription drugs fall under your plan’s deductible, you’ll need to pay for them when you pick them up from the pharmacy. Copayments do not count toward your deductible.

Services, treatments, items or supplies that are not covered under your plan.

At Harvard Pilgrim, we refer to an explanation of benefits as an Activity Summary. Please see Activity Summary for more information.

If your plan includes Harvard Pilgrim prescription drug coverage, your formulary is the list of drugs that are covered under your plan. Different Harvard Pilgrim plans offer different formularies, so your coverage may change if you switch plans. You can see all the drugs covered under your formulary in the drug lookup.

Habilitation services help a person keep, learn or improve skills and functioning for daily living and may include physical and occupational therapies and speech-language services.

HMO stands for health maintenance organization. An HMO is a type of insurance plan that requires you to get your care from a primary care provider (PCP) who belongs to your plan’s provider network. You will need your PCP’s referral for most kinds of specialty care.

These are care services that can be given in your home for an illness or injury.

Provide care that focuses on the quality of life for people experiencing an advanced, life-limiting illness, helping them live as fully and comfortably as possible.

HRA stands for health reimbursement arrangement. This is an account, set up by an employer, that can help you pay for your plan’s deductible costs.

HSA stands for health savings account. This is an account that can help you pay for qualified health care expenses. You need to have a federally qualified high deductible health plan, such as the Best Buy HSA HMO or HSA PPO, to be able to open an HSA. These accounts may be available through employers or through a bank.

Generally, this describes coverage for care that POS and PPO members receive from participating providers in the Harvard Pilgrim network. In-network coverage typically costs less than out-of-network coverage. In most cases, if you have a POS plan, you need to have a referral from your primary care provider (PCP) to another participating provider in order for in-network cost sharing to apply.

In an effort to ensure the new-to-market prescriptions that we cover are safe, effective and affordable, we delay coverage of many new drugs until a physician specialist reviews them. If your doctor feels you need a new medication, they can contact us to request coverage.

Medications that are not currently covered by us. If your provider feels you require this medication, your provider should contact us. They may submit a request for coverage to Harvard Pilgrim. We will cover the medication if it meets our coverage guidelines. If the request is approved, you will be covered for your prescription.

These are health professionals and hospitals that do not have contracts with Harvard Pilgrim to care for our members and are therefore not in our network. Harvard Pilgrim will not pay for care that HMO members receive from non-participating providers, except in a medical emergency. POS and PPO members can see these providers for covered services, but they usually pay higher cost-sharing amounts. Also, it’s possible that non-participating providers will charge more than Harvard Pilgrim’s allowed amount for the care they provide. In that case, you would be responsible for paying the difference between the provider’s charges and Harvard Pilgrim’s allowed amount.

Out-of-network coverage applies only to POS and PPO plans. Harvard Pilgrim will cover care that POS and PPO members receive from non-participating providers, but it usually costs more than in-network coverage. In addition, if you have a POS plan, you will — in most cases — have out-of-network coverage when you receive care for covered services from participating providers without your PCP’s referral.

This is a limit on the total amount of cost sharing you have to pay annually for covered services. This generally includes copayments, coinsurance and deductibles. After you meet your out-of-pocket maximum, Harvard Pilgrim will pay all additional covered health care costs.

These are health professionals and hospitals that have contracts with Harvard Pilgrim to care for our members and are therefore in our network. Not all Harvard Pilgrim plans have the same participating providers. Be sure to check your plan’s provider directory.

PCP stands for primary care provider. This is the medical professional (e.g., doctor, nurse practitioner or physician assistant) you see for routine care and when you are sick. PCPs are usually in specialties such as internal medicine, family practice or pediatrics. If you are covering family members on your policy, everyone can have a different PCP. HMO members need a PCP’s referral for most kinds of specialty care. Likewise, POS members need a PCP’s referral to participating providers for in-network coverage.

POS stands for point of service. This is a type of insurance plan that allows you to see participating providers and non-participating providers. Be sure to get your PCP’s referral to participating providers for in-network coverage and lower out-of-pocket costs. You’ll have out-of-network coverage — and higher out-of-pocket costs — when you get covered services from participating providers without your PCP’s referral or from non-participating providers.

PPO stands for preferred provider organization. This is a type of insurance plan that allows you to see participating providers as well as non-participating providers. You have in-network coverage when you receive care for covered services from participating providers and out-of-network coverage when you receive care for covered services from non-participating providers. You do not need a PCP, but we encourage you to have one.

This is the amount you pay for your health insurance every month. If you are on a group plan, you and your employer may share in the cost of your insurance premium. In addition to the premium, you usually have to pay other costs for your health care, such as a deductible, copayments and coinsurance.

A program to verify that certain covered benefits are, and continue to be, medically necessary and provided in an appropriate and cost-effective manner.

The need for your provider to tell us why it is medically necessary for you to receive a covered medication or service. We consult with your doctor(s) to provide you with better health outcomes, cost savings and assure your safety. Contact the doctor who recommended the medication or service. If the doctor believes the medication or service that requires PA is necessary for your treatment, they may submit a request for coverage to Harvard Pilgrim. We’ll cover the medication or service if it meets our medical necessity coverage guidelines.

This is the group of health professionals and hospitals that have contracts with Harvard Pilgrim to care for our members. Some of our plans have select or defined provider networks. That means only some of our providers are available to care for members who have that particular plan.

The quantity limit for a medication that can be purchased at any one time. A common QL is a 30-day supply, which is the maximum number of units needed for 30 days based on the prescribed daily/weekly dose. You’re covered for up to the quantity posted in our covered drug list. If your doctor believes you need to take more than that quantity, the doctor may submit a request for authorization.

These are treatments for disease or injury that restore or move an individual toward functional capabilities.

A skilled nursing facility is an inpatient extended care facility that provides a high level of medical care by or under the supervision of licensed health professionals, such as registered nurses (RNs) and physical, speech and occupational therapists.

These are doctors who have completed advanced education and clinical training in a specific area, such as dermatology, cardiology or urology.

You might receive a “surprise bill” (or unexpected bill) if: (1) you obtain services from a non-participating provider while you were receiving a service from a participating provider or facility, or (2) you obtain services from a non-participating provider during a service previously approved or authorized by Harvard Pilgrim where you did not knowingly select a non-participating provider.

Learn more about your rights and protections against surprise medical bills.

Generally, this means “category.” Our prescription drug plans put medications into different tiers with different cost sharing amounts. Some of our medical plans put providers into tiers with different cost sharing amounts, as well.

UCR stands for usual, customary and reasonable. This refers to the amount paid for a medical service in a geographic area and is based on what providers in the area usually charge for the same or similar medical service.

Urgent care services are provided for a condition that requires prompt medical attention but is not a medical emergency.