32 FULLY INSURED PLAN: A plan where the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs. GENERIC DRUG: A “twin” to a “brand name drug” once the brand name company’s patent has run out and other drug companies are allowed to sell a duplicate of the original. Generic drugs are less expensive, and most prescription and health plans reward clients for choosing generics. GENERIC STEP THERAPY: Plans used by pharmacies to encourage the use of lower cost generics and preferred brands. These highly effective solutions promote prescription benefit education and help to reduce our overall prescription costs. GINA: Title I of the Genetic Information Nondiscrimination Act (2008) prohibits the use of genetic information in employment or health insurance decision-making HOME HEALTH CARE: In home health care services for an injury or illness that may include skilled nursing care and physical, occupa- tional, and speech therapy. HOSPICE CARE: Program or facility that provides medical care and support services for terminally ill patients and their families. Its focus is to help make people as comfortable as possible at the end of their life, rather than trying to cure their illness or injury. Hospice care includes physical care, pain control, and counseling. HEALTH MAINTENANCE ORGANIZATION (HMO): A health benefits program that requires that the member receives care from the doctors and hospitals that are part of the plan’s network. HMO’s also require that the member select a primary care physician (PCP); generally a family practitioner, internist or pediatrician, who is part of the plan’s network. A referral is required from the primary care physician to see specialists in the network. HEALTH CARE FLEXIBLE SPENDING ACCOUNT (FSA): A benefit plan designed to allow employees to set aside pre-tax dollars to pay for eligible medically related expenses, such as medical, vision or dental exams, copays and deductibles, as well as other out-of- pocket expenses. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): Federal law designed to allow people to change jobs without fear of losing insurance because of a pre-existing condition. HIPAA also requires additional protections for the privacy of health information. INPATIENT CARE: Care that you receive in the hospital that requires an overnight stay. MANAGED CARE: A general term for organizing doctors and hos- pitals into health care delivery networks with the intent of lowering costs and managing the medical care. There are many different kinds of managed care plans including Preferred Provider Organization (PPO) plans, and Health Maintenance Organizations (HMO) plans. MEDICARE: A health insurance program administered by the Social Security Administration which is broken into two distinct categories: 1) Medicare Part A helps with hospital costs; and 2) Medicare Part B requires a monthly fee and is used to pay medical costs for people 65 years of age and older, some disabled people under 65 years of age and people with end-stage renal disease (permanent kidney failure treated with dialysis or a transplant). WSSC active employees 65+ can maintain their regular benefits plans. Contact HR for further details. MEDICARE APPROVED AMOUNT: The amount in which Medicare decides is a reasonable payment for a medical service. Medicare generally pays 80 percent of the approved amount and your sup- plemental WSSC insurance generally pays 20 percent. (This rule is different for active 65+ employees. Contact HR for further details.) MEDICARE SECONDARY PAYER: Is the term used by Medicare when Medicare is not responsible for paying first. (The private insur- ance industry generally talks about “Coordination of Benefits” when assigning responsibility for first and second payment.) MENTAL HEALTH PARITY ACT: Health plans that provide cover­ age for mental health and/or substance abuse treatment must provide benefits that are on par with med­ ical and surgical benefits. This means that health plans may no longer apply, to mental health and sub­ stance abuse treatment, limits or financial terms that don’t also apply to medical and surgical benefits. NETWORK: A group of doctors or health care providers that work with specific health insurance companies. Generally, you get your medical care from the health care providers within your insurance company’s network. OPEN ENROLLMENT PERIOD: The period of time designated by the employer’s health or other benefit plan when employees may enroll in new benefit plans or make changes to existing benefit plans for a new plan year. OUT-OF-PLAN (OUT-OF-NETWORK): This phrase usually refers to physicians, hospitals or other health care providers who are consid- ered non-participants in an insurance plans network. HMO members are generally not covered for out-of-network services except in emer- gency situations. Members enrolled in Preferred Provider Organiza- tions (PPO) and Point-of-Service (POS) plan’s may go out-of-network, but will pay higher out-of-pocket costs. Depending on an individual’s health insurance plan, expenses incurred by services provided by out- of-network health professionals may not be covered, or covered only in part by an individual’s insurance company. OUT-OF-POCKET MAXIMUM: The maximum dollar amount one would pay out of their own pocket for co-pays, coinsurance, or deductible for the year, excluding premiums. Once the out-of- pocket limit is met, the plan pays 100% of the allowed amount for covered services for the rest of the benefit period. OUTPATIENT CARE: Medical or surgical care that does not include an overnight stay in a hospital. PATIENT PROTECTION AND AFFORDABILITY CARE ACT (PPACA): enacted in March 2010. The Patient Protection and Affordable Care Act will ensure that all Americans have access to quality, affordable health care and will create the transformation within the health care system necessary to contain costs. Systemic insurance market reform will eliminate discriminatory practices such as pre-existing condition exclusions, eliminate lifetime and unrea- sonable annual limits on benefits and provide assistance for those who are uninsured because of a pre-existing condition. POINT OF SERVICE (POS): A plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). The insured may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or non-discounted charges from the providers. PRE-EXISTING CONDITION: A pre-existing condition is a health problem that existed before you apply for a health insurance policy or enroll in a new health plan. Glossary of Insurance Terms