Definitions continued
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. To help you better understand your health plan, the Affordable Care Act (ACA) requires insurers and group health plans to provide a new way to show benefits and define health care industry terms. These required documents are called the Summary of Benefits and Coverage, or SBC. The goal of the SBC is to help you more easily compare health plans so you can choose the one that’s right for you. SBCs are provided in a standard format, which may only be different based on the specific benefits offered by each plan. The summary plan descriptions (SPDs) are important documents that tell participants what plans provide and how they operate in greater detail. They provide information on when an employee can begin to participate in a plan, how services and benefits are calculated, when and in what form benefits are paid, and how to file a claim for benefits. SPDs can be found on the Human Resources Intranet. If you are unable to print an SPD, please contact the Benefits Office at 516-367-5226 to obtain a free copy of an SPD. A freestanding facility is an outpatient, diagnostic, or ambulatory center or independent laboratory that performs services and submits claims as a freestanding entity and not as a hospital. An alternate facility is a healthcare facility that is not a hospital and that provides one or more of the following services on an outpatient basis, as permitted by law: surgical services; emergency health services; and/or rehabilitative, laboratory, diagnostic, or therapeutic services. An alternate facility may also provide mental health services or substance use disorder services on an outpatient basis or inpatient basis (for example, a residential treatment facility). A place of service that is owned by a hospital and provides services that are billed under the tax identification number of the hospital.
OOP: Out-of-Pocket
PCP: Primary Care Provider
R&C: Reasonable and Customary or
UCR: Usual and Customary and Reasonable:
SBC: Summary of Benefit Coverage
SPD: Summary Plan Description
Freestanding Facility
Alternate Facility
Hospital-based services/facility
Virtual care visits are interacting with a designated virtual visit network provider using live video, audio, and instant messaging to communicate with their patients remotely.
Virtual Care Visits
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