Health Insurance Covered Lives Report - Definition of Terms Used

The following is a brief listing of the terms used in the reports. For more detailed explanations, please visit our Health Plan Definitions page.

EPO (Exclusive Provider Organization)

In an EPO you must use the providers who belong to the EPO or your expenses will not be covered. In other words, you cannot go "outside" the network for medical care.

 

Fee-for-Service (FFS) Plans

A traditional type of insurance in which the health plan will either pay the medical provider directly or reimburse you after you have filed an insurance claim for each covered medical expense. When you need medical attention, you visit the doctor or hospital of your choice. This approach may be more expensive for you and require extra paperwork.

 

Grandfathered Health Benefit Plan (GF)

As used in connection with the Section 1251 of the Patient Protection and Affordable Care Act (PPACA), a grandfather health plan is a group health plan that was created - or an individual health insurance policy that was purchased - on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their "grandfathered" status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.

 

Non-Grandfathered Health Benefit Plan (NGF)

A health benefit plan that is not grandfathered health plan as defined in Section 1251 of PPACA.

 

High Deductible Health Plan (HDHP)

A High Deductible Health Plan (HDHP) is a product designed to be combined with a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA). HDHP plans have a higher annual deductible than typical health plans and a maximum limit on the sum of the annual deductible and out-of-pocket medical expenses that you must pay for covered expenses. Out-of-pocket expenses include co-payments and other amounts, but do not include premiums. Refer to IRS - Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans.

 

POS (Point of Service)

Plans that allow you to go outside your network are called POS plans. Charges for services outside your network can be much higher, though.

 

PPO (Preferred Provider Organization)

In a PPO, insurance companies contract with doctors, hospitals, and other providers to form a "network." Depending upon your plan, you can sometimes get health care outside the network (someone or someplace not included in the network) but you will have to pay more. Unlike an HMO, you also have to pay a deductible and coinsurance. Also unlike an HMO, you usually can see a specialist without first being referred by your primary care physician, and you have much more freedom in choosing a doctor or hospital. PPOs in California are regulated by both this Department (CDI) and the California Department of Managed Health Care (DMHC).