Basic Health Glossary
| Term | Definition |
Puts your choices for health care into writing. It may also name someone to speak for you if you are not able to speak for yourself. May include a Durable Power of Attorney for Health Care or a Directive to Physicians or both. | |
You "appeal" or ask Community Health Plan to review a denied service or referral for a service. You must file an appeal within 180 calendar days from the date Community Health Plan resolved the complaint or denied the service. Community Health Plan will tell you we got the appeal within 5 calendar days of getting it. Community Health Plan will inform you of our decision within 14 calendar days of getting the appeal, or else write to you to say we need more time. Unless we have your written permission to take longer, the decision will take 30 calendar days or less from the date we get the request. | |
| |
Jointly run by DSHS and Basic Health, a program for children under 19 from low-income families. It provides extended benefits such as dental and vision care. Eligibility for Basic Health Plus is determined by DSHS. | |
Case managers are nurses who work with you and the doctors to help manage health care and insurance coverage. You may be referred or may ask to be in the Case Management program, but you are not required to be in it. This is a free service. | |
This Community Health Plan incentive program rewards you for getting the health care you need, such as prenatal exams and Well Child check-ups. | |
Coordination of benefits. Happens when you are covered by more than one health insurance plan at the same time. The other insurance plan must pay for all covered benefits first, and then Community Health Plan will pay for the remaining covered charges. | |
A description of health care coverage and benefits for Basic Health enrollees. The Washington State 2010 Basic Health Member Handbook is a certificate of coverage. | |
The percentage you pay when Community Health Plan pays less than 100% for covered services. For medical services, coinsurance does not apply until you have paid the annual deductible. You are responsible for paying 20% of the cost for some services that have a coinsurance. Community Health Plan pays the remaining 80%. For pharmacy, you pay 50% of the cost of Tier 2 drugs. See tier. | |
A set dollar amount you pay when you get certain services or treatments. For medical services, copays are not subject to deductible and do not apply toward your: For pharmacy benefits, your copay is $10 for Tier 1 drugs. See tier. | |
Community Service Office, Department of Social and Health Services (DSHS). See also DSHS. | |
The amount you pay before Community Health Plan starts to pay for some covered medical services. The deductible does not apply toward your out-of-pocket maximum. You are responsible for the first $250 of some costs before Community Health Plan pays the 80% coinsurance. The $250 deductible has to be met for each family member enrolled in Basic Health. There is no deductible for pharmacy for Basic Health members. | |
An advance directive that states your wishes for care at the end of life, when you may not be able to speak for yourself. For example, you may say that you do not wish to have treatments to prolong your life and you want to be allowed to die naturally. | |
Voluntary program for members with chronic, long-term diseases such as asthma and diabetes. Nurses work with you and the doctors to meet your care needs on a care plan to help you self-manage the condition. They also supply information about the condition. This is a free program. | |
The Washington State Department of Social and Health Services. DSHS runs Medicaid and, along with the Health Care Authority (HCA), jointly runs Basic Health Plus and the Maternity Benefits Program. | |
Diphtheria, tetanus, pertussis immunization that is part of a series of children’s “shots” during Well Child check-ups. | |
An advance directive that names another person to make decisions for you if you are not able to make decisions for yourself. | |
A situation when someone has a serious medical problem that needs care right away. It is an emergency if someone might die or be disabled if they do not get care right away. See What Is an Emergency? | |
Explanation of benefits. Community Health Plan sends an EOB each time an enrollee gets medical services. This statement explains:
The Explanation of Benefits also tracks deductible and out-of-pocket maximum for each enrolled family member. | |
Express Scripts, Inc. is Community Health Plan's pharmacy benefit manager. | |
A program for pregnant members that can provide:
| |
A list of approved prescription drugs developed by the Pharmacy & Therapeutics (P&T) Committee. Drugs are placed on the formula based on evidence-based review of their safety, effectiveness, and cost. Formulary drugs are approved for use or coverage by the Plan and will be dispensed to covered enrollees by drug stores in the network. See also P&T Committee. | |
A prescription drug that has the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. | |
grievance | A spoken or written complaint about anything that you are not happy with except for a denied service. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, personal relationship problems such as rudeness of a provider or employee, or failure to respect your rights. |
Washington State Health Care Authority. The state agency responsible for running Basic Health and jointly running Basic Health Plus and the Maternity Benefits Program with DSHS. | |
An organization such as Community Health Plan that offers health care coverage and contracts with HCA and others to provide member care. You choose a health plan when you join Basic Health. | |
Healthcare Effectiveness Data and Information Set. You have the right to written information about how Community Health Plan reports our performance statistics. We measure our performance by using HEDIS. You may ask to see the HEDIS data and have someone explain what they mean. | |
H influenza type B immunization that is part of a series of children’s “shots” during Well Child check-ups. It can also be given to adults. | |
ID cards are sent to every enrolled member of a family. You must show the ID card when you get care and when you go to the drug store. | |
Independent Review Organization. If you are not happy with the Community Health Plan Second Level Appeal Committee's decision, you can ask for an IRO to review the case. You must ask for the IRO review within 180 calendar days of the denial by the Second Level Appeal Committee. | |
A document that gives your instructions for the kind of care you want to get if you are seriously ill and not able to communicate. | |
The program coordinated with DSHS for eligible pregnant women. This program includes all Medicaid benefits, including maternity benefits, maternity support services, and maternity case management. Eligibility for the program is determined by DSHS. | |
A health care provider decides if a service or treatment is medically necessary. Medically necessary health care services are used to evaluate, diagnose, or treat an illness, injury, or disease or its symptoms. A covered service is “medically necessary” if it is recommended by your treating provider and the Community Health Plan medical director or provider designee, and if all of the following conditions are met:
For more information and definitions, please see Appendix A, Schedule of Benefits, in the Washington State 2010 Basic Health Member Handbook. | |
Measles, mumps, rubella vaccination that is part of a series of children’s “shots” during Well Child check-ups. | |
A Community Health Plan program, free to expectant mothers, that provides access to high-risk case management for complicated health problems. | |
The most coinsurance you will have to pay for each year for each covered family member. For medical services, only your coinsurance costs apply toward your out-of-pocket maximum of $1,500 per person, per calendar year. After you reach your out-of-pocket maximum, you do not have to pay coinsurance costs for the remainder of the calendar year. This means that for the rest of that year, Community Health Plan will pay 100% of all coinsurance costs. There is no out-of-pocket maximum for drugs. | |
Pharmacy and Therapeutics Committee. An independent committee, composed of Washington State providers and pharmacists from various medical specialties, that develops the Community Health Plan drug formulary by using the principles of evidence-based medicine. | |
Cervical cancer screening test. Also called Pap smear. | |
Primary care provider. Your main health care provider, who helps manage all parts of your health. PCPs may include pediatricians, family practitioners, general practitioners, internists, physician assistants (under the supervision of a physician), or advanced registered nurse practitioners (ARNPs). To get benefits, your PCP must provide or coordinate your care. The PCP will refer you if you need to see a specialist. The PCP's office or clinic may offer:
| |
Pneumococcal conjugate vaccination that is recommended once every 10 years. | |
Protected health information means any information that is about you, including information about your health care and treatment, your name, age, address, Social Security number, family, and employer. | |
Community Health Plan must approve some surgical admissions and procedures before the member gets the services. For instance, an admission to a hospital for surgery that is not urgent requires pre-certification. | |
An illness, injury, or condition for which, in the 6 months immediately preceding your effective date of enrollment in Basic Health:
| |
The medical care a woman gets while she is pregnant. | |
Office visit with your PCP or other provider for services such as physical exams, annual women’s health care, and immunizations (shots). | |
Community Health Plan must approve some services, supplies, or equipment before you get that service, supply, or equipment. For instance, you might need prior authorization before you get treatment from a specialist or for follow-up treatment when you are out of your service area. Community Health Plan also must approve some drugs. | |
provider | A health care professional (such as a doctor, nurse, or internist) or facility (such as a hospital or clinic). |
Office visit with your PCP or other provider for medical problems that are not urgent or an emergency. | |
A health care provider other than your primary care provider who focuses on one specific area of medicine, such as a surgeon or a mental health counselor. In most cases, your PCP must provide a written referral to see a specialist. | |
If you have a complicated or serious medical problem, you have the right to a referral that lasts for a long period of time. This is called a standing referral. A standing referral is valid only until the end of the designated period or until your coverage ends. | |
When another party is responsible to pay for health care services you get because of an injury or illness. For example, auto insurance might pay if you are injured in a car accident and workers' compensation might pay if you are hurt on the job. See also third party liability. | |
Tetanus, diphtheria vaccination, usually part of a series of preventive care immunizations. | |
When another party is responsible to pay for health care services you get because of an injury or illness. For example, auto insurance might pay if you are injured in a car accident and workers' compensation might pay if you are hurt on the job. See also subrogation. | |
A category of drugs related to the pharmacy benefit. Your cost for prescriptions depends on the tier the prescription falls within. | |
Office visit with your PCP or other provider for medical problems that need care right away, but are not an emergency. |