GLOSSARY

Balance Billing, Ohio Med. Non-network providers may bill the patient the difference between Medical Mutual’s allowed amount and actual charges. Network providers will not balance bill you.

Board Certified. This signifies that a physician has successfully completed the requirements of a particular specialty and has passed the certification examinations administered by the specialty board.

Brand-name Medication. A medication marketed by a major pharmaceutical company under a trade name with the protection of a patent. They are usually more expensive than a generic equivalent.

Case Management (PReview). Ohio Med. Special intensive medical evaluation of persons with designated illnesses or injuries. These are usually severe and potentially high-cost situations, such as serious head injuries, neonatal cases and back injuries. The goal is to develop medically acceptable, less costly alternate courses of treatment. For example, Case Management may suggest rental of special equipment and provision of full-time nursing care at home in lieu of extended hospitalization.

Copay. A percentage of the charges for which you are responsible when receiving covered services. Typically 20 percent.

Coinsurance. A percentage of the charges paid by the insurer. Typically 80 percent.

Covered Service. A provider’s service or supply for which the plan will pay. Not all services prescribed or performed by a provider are necessarily a covered service.

Deductible. (Ohio Med) The amount you must pay out of your pocket each benefit period before Ohio Med will begin paying. Some services do not require payment of a deductible before coverage begins. The drug copays do not go toward the medical deductible.

Diagnostic Service. A test or procedure performed to detect or monitor an injury, condition or illness.

Effective Date. The date your coverage begins. After a typical open enrollment, it is July 1. Upon hire, it is usually the first day of the month following the month in which you signed and submitted your application form.

Emergency, Medical. The sudden and unexpected onset of a severe medical ailment, condition, disease, illness or disorder, including severe pain, requiring emergency services.

Generic Medication. A medication marketed under its biochemical name rather than under a trade brand name. A generic medication differs from its brand-name counterpart in the composition of its inert components, and is typically less expensive than its brand-name equivalent.

Hospice. A facility or service which provides supportive care for terminally ill patients and their families.

Mail-Order Medication Program. A prescription medication service which fills prescriptions through the mail. A mail-order medication program provides larger discounts that are possible because of high volume. In the Ohio Med plan, you must use the mail-order plan for long term prescriptions.

Medical Mutual. The third party administrator selected to administer the Ohio Med plan on behalf of the Ohio Department of Administrative Services.

Medical Necessity (or Medically Necessary). Only those covered services, supplies and hospital admissions that are medically necessary are payable (except some preventive services). Medically necessary services and supplies are those that are appropriate with regard to standards of good medical practice, appropriate to the illness or injury for which they are performed, not solely for the convenience of you or a provider, or the most appropriate supply or level of service that can be safely provided to you.

Multi-Source Medication. A brand name medication which has a generic equivalent.

Network Provider. Any health care provider who has contracted with the health plan to provide services and abide by health plan policies and whose services are allowed by the plan. In the case of Ohio Med, enrollees receive maximum reimbursement and some additional benefits when they use network providers.

Non-Network Provider. A health care provider who has not contracted with the health plan to provide services. HMOs will not reimburse you when you use such a provider except in emergency situations. Ohio Med allows you to use these providers but at a reduced reimbursement rate and certain plan safeguards may not apply.

Other Facility Provider, Ohio Med. Ambulatory Surgical Facility*, Dialysis Facility, Home Health Care Agency*, Hospice Facility or Skilled Nursing Facility.

Other Professional Provider, Ohio Med. Only the following persons or entities which are licensed as required: dentist; doctor of chiropractic medicine*; durable medical equipment* or prosthetic appliance vendor; laboratory (Medicare approved); licensed practical nurse; licensed vocational nurse, mechanotherapist licensed before November 3, 1975; nurse midwife; occupational therapist; physical therapist*; podiatrist*; registered nurse; Urgent Care provider.

Out-of-Pocket Maximum (OPM). The maximum amount you must pay for eligible expenses each year before the health plan begins paying 100 percent of subsequent eligible expenses in that year. For all health plans, the OPM per person is $1,000 or $2,000 for a family (except the Ohio Med non-network OPM is $2,000 for single and $4,000 for family).

Physician. A person who is licensed and legally authorized to practice medicine.

Preferred Drug List (often referred to as a formulary). A list of approved medications for which the plan will pay.

Preferred Provider Organization (PPO), Ohio Med. A network of hospitals and doctors who have agreed to serve Ohio Med PPO members at a discount. If you use a hospital or provider in the PPO network, you are covered at a higher percent than if you go to a provider outside the network. Employees can use providers who are not part of the PPO but will pay a higher copayment. PPO providers will file claims for you and accept Ohio Med’s allowed amount as payment in full for most covered services. For some benefits and services, you are required to pay deductibles and copayments.

PReview Managed Care, Ohio Med. Medical Mutual’s cost containment program. Many medical procedures and practices can be misused. To save time and money, the use of certain procedures must be reviewed to ensure that there is not a more effective and less expensive alternative.

Provider. A Hospital, Other Facility Provider, Physician or Other Professional Provider.

Skilled Nursing Facility. A facility which primarily provides 24-hour inpatient skilled care and related services to patients requiring convalescent and rehabilitative care. Such care must be provided by either a registered nurse, licensed practical nurse or physical therapist performing under the supervision of a physician.