Glossary

Refer to these health and medical terms to help you understand your Summary of Benefits and Coverage and other important plan documents.

Behavioral Health – Diagnosis and treatment of mental health and substance abuse disorders.

BenefitThe dollar amount Quartz contributes toward the payment of covered health care services.

Brand DrugA prescription drug that is protected by a patent, supplied by a single company, and marketed under the manufacturer's brand name.

Covered Services or Covered Health Care ServicesSpecific health care services covered under a member's health plan. Covered health services include primary care services, hospitalization, outpatient care, ambulatory and emergency care.

Certificate of CoverageThe Certificate of Coverage is a document that defines services covered by a member's health plan. It also includes essential terms, conditions affecting eligibility, and services excluded from coverage.

ClaimA request to Quartz seeking Quartz's payment toward the health care services covered under your health plan. You or your provider may submit a Claim.

CoinsuranceThe percentage of the cost you pay for covered health care, after you've paid your deductible.

Let's say Quartz's allowed amount for an office visit is $100 and your coinsurance is 20 percent.

  • If you've paid your deductible, you pay 20 percent of $100, or $20. Quartz pays the rest.
  • If you haven't met your deductible, you pay the full amount of $100.

CopaymentA fixed amount you pay for a covered health care service. For example, a copay of $20 means that when you go to the doctor and receive a bill that shows the cost of $130, you will only pay the fixed amount of $20 and Quartz will pay the rest.

DeductibleA predetermined amount of money a member or family must pay before Quartz will make a payment toward covered services. Deductibles accumulate during your benefit period (usually a year) and reset at the end of the benefit period.

DependentA person who receives health insurance through a spouse, parent or other family member.

Fee ScheduleA Fee Schedule lists the maximum amount of money Quartz will reimburse a hospital or health care provider for covered services.

FormularyA document that lists prescription drugs covered by Quartz health plans. Your plan documents state the formulary that applies to your plan.

Generic DrugA chemically-equivalent copy designed from a brand-name drug whose patent has expired (typically less expensive and sold under the common name).

HMO (Health Maintenance Organization)A form of health insurance in which members prepay a premium for health services and which generally includes a defined set of services made available through a defined panel of physicians at a preset price.

HSA (Health Savings Account)A tax-advantaged way to save money for health care expenses. Members can establish a Health Savings Account when they have a High Deductible Health Plan (HDHP).

MemberA person enrolled in a Quartz health plan.

NetworkA group of providers that have a contract with Quartz. Quartz contracts with health care providers to obtain lower prices for our members. By building a network of high-performing health care providers, Quartz seeks to make the best care available to our members at the lowest price.

Nurse PractitionerNurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician. Nurse Practitioners cannot serve as a PCP for Quartz members, but are available for routine exams, urgent/problems visits, and follow-up care.

Out-of-Pocket CostsYour expenses for medical care that are not paid by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

POS (Point of Service)A managed care plan that offers coverage In-Network and Out-of-Network. Members pay lower out-of-pocket costs when they receive care from In-network providers.

PPO (Preferred Provider Organization)A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of providers. You pay less if you use providers that belong to Quartz's network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Physician Assistant (PA)A health care professional who is licensed to provide patient education, evaluation, and health care services. A physician assistant works under the supervision of a doctor to provide medical care. PAs cannot serve as a PCP for Quartz members, but are available for routine exams, urgent/problems visits, and follow-up care.

PractitionerA person who supplies health care services, i.e., physician, psychologist, nurse practitioner.

Prior AuthorizationA request for prior authorization is submitted by members and providers. Quartz reviews the request and responds by letting the member and provider know whether the service, treatment, or supply is covered under the member's plan.

ProviderA person or entity that supplies health care services. For example, Providers include pharmacies, hospitals or other health care facilities that provide services to members.

Schedule of Benefits or Summary of Benefits and CoverageAn easy-to-read summary that shows health care services you may need and the benefit Quartz contributes toward paying the cost of those health care services.

SubscriberThe person in whose name a health insurance certificate or insurance policy is held.

Usual, Customary and Reasonable (UCR)The amount covered by Quartz based upon the customary charges of all providers within a given geographic area for the same or similar health care service.