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These terms are defined for general information purposes only; certain terms may have varying definitions based on state law.

A

Allowable Expense(s)
Any Medically Necessary health expense, part or all of which is covered under any of the plans covering the Member for whom claim is made. A health care service or expense including deductibles, coinsurance or Copayments that is covered in full or in part by any of the plans covering the Member. This means that an expense or service or a portion of an expense or service that is not covered by any of the plans is not an Allowable Expense. Plan documents will show examples of expenses or services that are or are not allowable.

Ambulatory Surgery
Surgical procedures performed that do not require an overnight hospital say. Also see Outpatient Surgery.

Appeals
A process used by a member to request the health plan re-consider a previous authorization or claim decision.

Authorization
See Preauthorization/Precertification

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B

Benefit
Payment received for covered services under the terms of the policy.

Benefit Period
The maximum length of time for which benefits will be paid.

Brand Name Drug
A prescription drug which is protected by trademark registration.

 

 

C

Case Management
A process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize the outcome.

Chemotherapy
Treatment of malignant disease by chemical or biological antineoplastic agents.

Chiropractic Care
An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.

Claim
A request for payment of benefits for health care services provided to a member.

Coinsurance
The portion of covered expenses that a member is responsible for paying, after first meeting any applicable deductible amount.

Contract
A legal agreement between an individual subscriber or an employer group ("Contractholder"), and, a health plan that describes the benefits and limitations of the coverage. Also known as a Benefit Certificate or Policy.


Coordination of Benefits (COB)
A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their benefits and provides the authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision; it does not have to pay its benefits first. Plan documents will include a description of the Coordination of Benefits provision.

Copayment
The specified dollar amount or percentage required to be paid by or on behalf of a Member in connection with benefits.

Covered Benefits or Covered Services
Those medically necessary services and supplies which are covered in whole or in part under the plan, subject to all the terms and conditions of the group agreement or group insurance policy

Custodial Care
Any type of care where the primary purpose of the type of care provided is to attend to the Member's daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples of this include, but are not limited to, assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of non-infected, post-operative or chronic conditions, preparation of special diets, supervision of medication which can be self-administered by the Member, general maintenance care of colostomy or ileostomy.

Customary and Reasonable
The amount customarily charged for the service by other providers in the same geographic area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient. Also called "Usual, Customary, and Reasonable"(UCR).

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D

Day Treatment Center
An outpatient psychiatric facility which is licensed to provide outpatient care and treatment of mental and nervous disorders or substance abuse under the supervision of physicians.

Deductible
An amount that a Member must pay for Covered Services in a specified time period in accordance with the Member's Plan before the Plan will pay benefits.

Dependent
A person who is eligible to be enrolled for coverage by the subscriber as determined by the employer and agreed upon with the plan. Examples would be a subscriber's spouse or child.

Diagnostic Tests
Tests and procedures ordered by a provider to determine if a patient has a specific condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include, but are not limited to, radiology, ultrasound, nuclear medicine, and laboratory and pathology services or tests.

Durable Medical Equipment (DME)
Equipment which is a) made for and mainly used in the treatment of a disease or injury; b) made to withstand prolonged use; c) suited for use while not confined as an inpatient in the Hospital; d) not normally of use to persons who do not have a disease or injury; e) not for use in altering air quality or temperature; and f) not for exercise or training.

Drug Formulary
A listing of prescription drugs and insulin established by the health plan which includes both Brand Name Prescription Drugs, and Generic Prescription Drugs. This list is subject to periodic review and modification by the health plan. Drugs listed on the formulary are covered under our managed prescription drug plans, with copayments that may vary based on plan design. Certain non-formulary drugs are also covered under some plan designs. Also called Formulary.

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E

Effective Date
The date on which the coverage under a member's plan goes into effect at 12:01a.m.

Emergency
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (I) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part. Also called Medical Emergency.

Enrollee
See Member

Exclusions
Specific conditions or circumstances that are not covered for benefits under the Plan.

Experimental Procedures
A drug, device, procedure or treatment will be determined to be experimental if:
There is not sufficient outcome data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or.

Explanation of Benefits
For certain Aetna plans, an Explanation of Benefits form is provided to members to explain how the payment amount for a health benefit claim was calculated. Among other things, the Explanation of Benefits may explain the claims appeal process.

F

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G

Generic Drug
A prescription drug which is not protected by trademark registration, but is produced and sold under the chemical formulation name.

H

Health Benefit Plan
The health insurance or HMO product offered by a licensed health benefits company that is defined by the benefit contract and represents a set of covered services or expenses accessible through a provider network, if applicable, or direct access to licensed providers and facilities.

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Health Maintenance Organization (HMO)
A third party, usually a legal entity, which arranges payment for the provision of basic and supplemental health services to its members from a network of independently contracted providers and facilities on a prepaid or reduced fee basis. For most plans, members are required to select a network primary care physician to provide routine care and provide referrals for specialty and hospitals services when appropriate. Some Aetna HMO plans do not require the member to select a PCP or obtain referrals and members can self refer for covered services within the network. Some Aetna plans provide coverage for services from out-of-network providers.

Home Health Care
Skilled nursing and other therapeutic services provided by a home health care agency in a home setting as an alternative to confinement in a hospital or skilled nursing facility.

 

Hospice Care
This is palliative and supportive care, either on an inpatient or outpatient basis, given to a terminally ill person and to his or her family. The focus of hospice programs is to enable terminally ill patients to remain, for as long as they can, in the familiar surroundings of their home.

Hospital
An institution rendering inpatient and outpatient services, accredited as a Hospital by the Joint Commission on Accreditation of Health Care Organizations, the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna as meeting reasonable standards. A hospital may be a general, acute care, rehabilitation or specialty institution.

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I-L

ID Card
Your Aetna member ID card provides proof of your Aetna coverage. An ID card is sent to you after we accept your enrollment form. As of your effective date, your copy of the enrollment form may be used as a temporary membership card until you receive your permanent card. Your Aetna ID card includes your member identification number, as well as your toll-free phone number to contact Aetna Member Services. If you need to request a new ID card, you may do so through our Member Services page.

Indemnity Plan
A traditional indemnity plan allows members flexibility in their choice of recognized health care providers for covered expenses. Members are responsible for seeking care, initiating precertification, paying for services rendered, and submitting claims for reimbursement of covered services. Indemnity plans traditionally have out of pocket expenses such as deductibles and coinsurance which the member must pay before any expenses are paid under the plan. Benefit maximums and lifetime maximums also apply to the plan.

In-Network
Refers to the use of providers who participate in the health plan's provider network.

Infusion Therapy
Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition which is the delivery of nutrients into the gastrointestinal tract by tube.

Inpatient Care
Service provided after the patient is admitted to the hospital. Inpatient care lasts 24 hours or more.

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M

Managed Care
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires pre-authorization of certain services.

 

Member
A subscriber or dependent who is enrolled in and covered by a health care plan. Also called Enrollee.

Member Services
The Aetna Member Services department assists members with questions about plan benefits and exclusions and, if applicable to your plan, selecting or changing a primary care physician (PCP). Calling the toll-free number on your ID card will connect you with your plan's Aetna Member Services office. If you do not have your ID card yet, contact your employer's benefits office for your Member Services toll-free number.

Mental Disorder
A dysfunctional manifestation in the individual that may be physical, psychological or behavioral, and for which treatment is generally provided by under the direction of a mental health professional such as a psychiatrist, a psychologist or a psychiatric social worker.

N

National Committee for Quality Assurance (NCQA)
The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that evaluates managed care plans. The NCQA accreditation process is nationally recognized and evaluates how well a health plan manages all aspects of its medical delivery system and the extent to which it continuously improves health care for its members.

National Medical Excellence Program
Our National Medical Excellence Program® helps eligible members access covered treatment for solid organ transplants, bone marrow transplants, and certain other rare or complicated conditions at participating facilities experienced in performing these services. The program has three components:
National Transplantation Program, designed to help arrange care for solid organ and bone marrow transplants
National Special Case Program, developed to coordinate arrangements for treatment of members with complex conditions at tertiary care facilities across the country when that care is not available within 100 miles of the member's home

Necessary, Medically Necessary, Medically Necessary Services, or Medical Necessity
Services or supplies that are appropriate and consistent with the diagnosis in accordance with accepted medical standards as described in the Covered Benefits section of the plan documents. Medical Necessity, when used in relation to services, shall have the same meaning as Medically Necessary Services. This definition applies only to the determination by the Plan of whether health care services are covered benefits under the plan. All services are subject to the exclusions and limitations described in the plan documents.

Network
Physicians, hospitals and other health care providers who contract with Aetna to participate in health benefits plans. For certain Aetna plans, a member must access care through the network to receive the maximum level of benefits. Also called Provider Network.

Non-Participating Provider
This term is generally used to mean providers who have not contracted with a health plan to provide services at reduced fees. Also called Non-Preferred Care Provider.

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O Occupational Therapy
Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.

Out-of-Network
The use of health care providers who have not contracted with the health plan to provide services. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverages can go out-of-network for covered expenses, but will pay additional costs in the form of deductibles and coinsurance and will be

The maximum out of pocket amount that an enrollee will have to pay for expenses covered under the health plan. The maximum may be a coinsurance maximum or a copayment maximum. Generally the out of pocket maximum is calculated by the sum of all paid deductible and copayment or coinsurance amounts. Some POS plans may have two types of out of pocket maximums, and the member is required to meet both maximums before the plan pays expenses 100%. Once member reaches the out of pocket maximum(s), the plan pays 100% of expenses for covered services.

Outpatient Care
Care provided in a clinic, emergency room, hospital or non-hospital surgical facility ("SurgiCenter") without admission to the hospital or facility.

Outpatient Surgery
Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office. Also see Ambulatory Surgery.

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P-Q

Partial Day Treatment
A program offered by appropriately licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.

Participating Provider
Any physician, hospital, skilled nursing facility, or other individual or entity involved in the delivery of health care or ancillary services which contracts to provide Covered Services to Members for a negotiated charge. Also called Preferred Care Provider.

PCP
See Primary Care Physician

Physical Therapy
Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.

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Plan Documents
Plan documents include the Group Agreement, Group Policy, and Certificate or Evidence of Coverage (or Certificate of Insurance).

Point-of-Service Plan
A point of service plan provides benefits for covered services received from both participating and non-participating providers. When you enroll in a point-of-service plan, you choose a primary care physician (PCP) for yourself and

Preauthorization / Precertification (Also known as Authorization, Certification, or Prior Authorization)
Certain healthcare services, such as hospitalization or outpatient surgery, require precertification with

Pre-Existing Condition
A health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to enrollment in a new health plan. Some pre-existing conditions may be excluded from coverage during a specified timeframe after the effective date of coverage in a new health plan. Plan documents will provide specific information on pre-existing conditions.

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Prescription
An order of a prescriber for a prescription drug. If it is an oral order, it must promptly be put in writing by the pharmacy.

Primary Care Physician (PCP)
A Participating Physician who supervises, coordinates and provides initial care and basic medical services as a general or family care practitioner, or in some cases, as an internist or a pediatrician to members, initiates their Referral for specialist care, and maintains continuity of patient care.

Prosthetic Devices
A device which replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent, or is malfunctioning.

Provider
A licensed health care facility, program, agency, physician, or health professional that delivers health care services.

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R

 

Reasonable Charge
The charge for a covered benefit, which is determined by Aetna to be the prevailing charge level, made for the service or supply in the geographic area where it is furnished. Aetna may take into account factors such as the complexity, degree of skill needed, type or specialty of the Provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Reasonable Charge for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area.

Referral
Specific directions or instructions from a Member's PCP, in conformance with Plan policies and procedures, which direct a Member to a Participating Provider for medically necessary care. A referral may be written or electronic.

Respiratory Therapy
Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.

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S

Second Opinion
The voluntary option or mandatory requirement to visit another physician or surgeon for an opinion regarding a diagnosis, course of treatment or having specific types of elective surgery performed.

Service Area
The geographic area the HMO or PPO is licensed to operate, where applicable, or when licensing is not required, the geographical area where an adequate network is established to provide the services covered under the benefit plan.

Skilled Nursing Facility (SNF)
An institution or a distinct part of an institution that is licensed or approved under state or local law, and which is primarily engaged in providing skilled nursing care and related services as a Skilled Nursing Facility, extended care facility, or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by the health plan to meet the reasonable standards applied by any of the aforesaid authorities.

Speech Therapy
Treatment for the correction of a speech impairment which resulted from birth, or from disease, injury, or prior medical treatment.

Subscriber
The employee covered under an employer's group agreement or group insurance policy. The subscriber can enroll eligible dependents as determined by the contract holder under family coverage.

Specialist
A Physician who provides medical care in any generally accepted medical or surgical specialty or subspecialty.

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TU-V

Usual, Customary, Reasonable (UCR)
See Customary and Reasonable

Urgent Care
Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.

W

Well Baby/Well Child Care
Generally, refers to routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of eight.

Wellness Program
A health management program which incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventing illness and disability which respond positively to lifestyle related interventions.

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