Definitions
United Healthcare (UHC) developed the United Health Premium designation program, which recognizes physicians that meet guidelines for providing quality and cost efficient care. These physicians are designated as Premium Tier 1 and are displayed publicly on myuhc.com and in UHC’s physician directory. The program uses national industry standards to evaluate for quality and local market benchmarks for cost efficiency across 25 specialties, including family practice, internal medicine, pediatrics, cardiology, and orthopedics. The fact that a doctor does not have a quality designation does not mean that the doctor does not provide quality health services. All doctors who are part of the UHC network must meet UHC’s standard credentialing requirements. Medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount was paid. A cost-sharing arrangement in which a covered person pays a specified charge for a specified service, such as $20 for an office visit. The covered person is responsible for payment at the time the health care is rendered. Our co-payments are fixed amounts for physician office visits, prescriptions, or hospital services for which the patient is responsible to pay. DED is a portion of the benefits, under a policy, that the employee and dependents must satisfy before any reimbursement occurs. This is called the individual deductible. A dental health maintenance organization (DHMO) is a structured type of dental plan. In this type of plan, a set group of dentists provides broad and affordable care at a low monthly pre- mium. The dentists who work with DHMOs receive a fixed fee each month. Most of the work is done at no cost or for a reduced price. You may need to make a copayment for some types of work. You will need to choose a primary dentist to work with and you must let Cigna know if you want to change your dentist. There are no waiting periods, calendar year maximums, deductibles, or claim forms when you have a DHMO plan. Your dependent child can remain covered under your health plan through the end of the month in which s/he turns 26 regardless of marital or student status or if they have access to an employer-sponsored plan. However, under the Dental Plan, your unmarried child can re- main on the plan through the end of the month in which s/he turns 22 or through the end of the month in which s/he ceases being a full-time college student, up to age 26. Each August, you will be required to provide supporting documentation that your unmarried child over age 22 is a full-time student. OOP is the portion of payments for covered health services required to be paid by the member, including co-payments, deductibles, and coinsurance. The OOP maximum is the maximum amount of co-payments, deductibles, and coinsurance that the member will have to pay each calendar year. Once the OOP maximum has been met, the plan will pay 100% of covered medical expenses for the remainder of the calendar year. A primary care physician or primary care provider (PCP) is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. This can be a physician in general practice, family practice, pediatrics, internal medicine, or gynecology. This is a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. It creates a maximum that is allowed for a particular service based on the geographical area and the charges for the same service within that area. This data is collected and compiled, and an R&C/UCR amount is determined.
Tier 1 Provider
Co-Insurance
Co-Payment
DED: Deductible
Dental Health Maintenance Organization (DHMO)
Dependent Child(ren)
OOP: Out-of-Pocket
PCP: Primary Care Provider
R&C: Reasonable and Customary or
UCR: Usual and Customary and Reasonable:
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