Understanding Health Plans
Health Plans 101
Health insurance protects your family in the event of an accident or unexpected illness.
Members can be part of an employer group or purchase insurance on an individual basis, directly from the insurer. If you have a job, your employer may pay part of your premium. Your part of the premium is usually deducted from each paycheck. If you are self-employed or have individual insurance, you pay your premium to the insurance company directly.
Insurance companies offer different health plans. The benefits offered by each plan can vary. Sometimes you have to go to certain doctors or clinics. Sometimes you share the cost of medications with the insurer, and sometimes the insurer covers the full expense. It is very important to know what services your plan covers and the amount the insurer will pay for services. You can access your benefits and learn more about your specific plan through MyChart.
Estimate Out-of-Pocket Costs
Determine costs you may incur prior to receiving health care services using the Determination of Benefits Form, which can be found on MyChart. To complete the form, you will have to ask your provider for medical coding information, including procedure codes, procedure modifiers and unit codes for the services.
What is a claim?
A claim is a detailed invoice sent to Quartz seeking payment for covered health care services. This invoice shows exactly what services you received.
Understanding Your Plan
Most health care plans have cost-sharing that you are responsible for depending on the care you receive. These payments are called out-of-pocket expenses. They fall into the following categories:
- Deductible: The amount you must pay for covered health care services before your plan begins to pay. For example, if the deductible is $500, your health plan will not pay anything until you have paid out $500. The deductible may not apply to all services.
- Coinsurance: The percentage of costs of a covered health care service for which you are liable for after the deductible has been met. For example, if your health plan pays $100 for an office visit, at a 20% coinsurance rate, you would pay $20.
- Copayment (or Copay): A fixed amount you pay for a covered health care service, usually at the time you receive the service. The amount may vary depending on the type of service you receive.
- Usual, Customary, and Reasonable Charge (UCR): The amount your health plan will pay for a medical service in a geographic area based on what other providers in that area usually charge for the same kind of service. You may be responsible for paying charges that are above the UCR and other out-of-pocket costs.
Understanding Your Explanation of Benefits (EOB)
An EOB is not a bill, but it contains helpful, important information about your plan benefits and Quartz’s share of your medical expenses.
Your coverage through Quartz pays a substantial portion of your family’s medical expenses. Here’s how it works:
- When you go to an in-network doctor, we will receive a bill from your doctor’s office and pay our portion. The portion we pay depends on the health care plan you have in place. Once we’ve reviewed the bill and paid our portion, we’ll send you an Explanation of Benefits (EOB) statement.
- An EOB lists the total cost of health care services received, the amount Quartz paid, and the remaining amount owed to the provider. An EOB is not a bill — it’s just a notice of what Quartz paid according to your plan benefits. Your health care provider will send you a bill if they require additional payment from you.
- Quartz mails an EOB statement to the member who received the health care service, even if the claim is for a child. In many cases, we are required by law to do this in order to protect member privacy.
Next Steps
Pharmacy Benefit Terms
Deductible
This is the amount you must pay for covered health care and drugs before your health plan begins to pay. Your drug coverage may have a deductible that includes both drug and medical services costs. Or, your deductible may only count your drug costs.
Once you have met your deductible, your drug coverage provides benefits for covered drugs for the rest of the coverage period. Your share of the cost for each claim may include a copay or coinsurance. Your plan pays the rest of the cost of the drug.
Co-Payments (or CoPays)
This is a fixed amount you pay based on the category or tier your medicine is in. You can find this information on your Drug Formulary.
Below is an example of how CoPays are related to Tiers
Copay Tier |
Example Copay |
|
|---|---|---|
|
Preferred Generics |
1 |
$10 |
|
Preferred Brands |
2 |
$35 |
|
Non-preferred (generics or brands) |
3 |
$60 |
|
Specialty Medications |
4 |
$100 |
|
Outcomes Benefit (drugs noted with RXO on the Formulary) |
Outcomes |
$5 |
Examples of common benefits are described. Your employer may have purchased a plan that is a modification of the listed descriptions.
Co-Insurance
This is the percentage you pay for a medication or service. For example, if your medication costs $100, your coinsurance of 20% would be $20. Since the prices of drugs can change, your cost share amount for that drug may change from time to time.
Out-of-Pocket Limit
Most plans include an out-of-pocket (OOP) limit. An OOP limit is the most you or your family will pay during a coverage period for covered charges. The coverage period for most plans is 12 months.
Within a family, there may be two types of OOP limits: individual and total family. Each individual in a family may have OOP limits. Once a family member has met the individual limit, that family member pays no OOP costs for the rest of the coverage period. There may also be family OOP limits. Once the entire family has met the family OOP limit, no one in the family will pay OOP costs for the rest of the coverage period.
Population health is based on three main ideas:
- Use data to help health care providers do a better job of taking care of patients.
- Work with health care providers, patients, and communities to help transform how people are cared for. The only way to make a real difference is to work together.
- Make sure that health care meets the needs of different groups of people at different times in their lives.
We offer health management programs, online screenings, and other tools to help members focus on their health. We look at the bigger picture, too. We want to improve the health of our community. Our initiatives to enhance health across our community are called “Population Health.” One of the most important parts of population health is prevention.
People may not be able to take care of themselves for several reasons. They may not have access to health care. Perhaps they don’t know exactly what they need to do, or they’re too busy to really pay attention to their health.
Quartz works with health care providers to support local programs, such as initiatives to help people conveniently get flu shots. We offer resources that help support healthy pregnancies and promote vaccinations in young children. As the health care providers in our networks develop new programs, Quartz will work alongside them to provide feedback and other support.
Insurance Terms
Behavioral Health
Diagnosis and treatment of mental health and substance abuse disorders
Benefit
The dollar amount Quartz contributes toward the payment of covered health care services
Brand Drug
A 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 Services
Specific health care services covered under a member’s health plan; covered health services include primary care services, hospitalization, outpatient care, and ambulatory and emergency care
Certificate of Coverage
A document that defines services covered by a member’s health plan; this also includes essential terms, conditions affecting eligibility, and services excluded from coverage
Claim
A 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.)
Coinsurance
The percentage of the charge for covered services that you have to pay after you pay the deductible
- Example: If Quartz’s allowed amount for an office visit is $100 and your coinsurance is 20%:
- After you’ve paid your deductible, you pay 20% of $100, or $20. Quartz pays the rest.
- If you haven’t met your deductible, you pay the full amount of $100.
Copayment
A 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 a cost of $130, you will only pay the fixed amount of $20 and Quartz will pay the rest.)
Deductible
A 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
Dependent
A person who receives health insurance through a spouse, parent, or other family member
Fee Schedule
A Fee Schedule lists the maximum amount of money Quartz will reimburse a hospital or health care provider for covered services
Formulary
A list of prescription drugs covered by Quartz health plans; your plan documents state the Formulary that applies to your plan
Generic Drug
A 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 an HSA when they have a High Deductible Health Plan (HDHP)
Member
A person enrolled in a Quartz health plan.
Network
A 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 Practitioner (NP)
Nurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician; NPs cannot serve as a PCP for Quartz members, but are available for routine exams, urgent/problems visits, and follow-up care
Out-of-Pocket Costs
Your 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
Participant
A person who participates in the health benefit plan offered by their employer/plan sponsor
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.)
Practitioner
A person who supplies health care services (i.e., physician, psychologist, nurse practitioner)
Prior Authorization
A 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
Provider
A 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 (SOB)/Summary of Benefits and Coverage
An 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
Summary Plan Description (SPD)
An easy-to-read summary that shows health care services you may need and the benefit your employer contributes toward paying the cost of those health care services.
Subscriber
The 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.
Medical Terms
Allergy and Immunology
Diagnosis and treatment of allergic conditions and diseases of the immune system
Anesthesiology
Administration of anesthesia to achieve temporary, partial, or complete loss of sensation to a patient undergoing surgery
Audiology and Speech – Language Pathology
Diagnosis and treatment of hearing, speech, and language disorders
Behavioral Health
Diagnosis and treatment of mental or behavioral health problems such as depression, eating disorders, substance abuse, or anxiety disorders; practitioner types include psychiatrists, psychologists, and counselors
CNM (Certified Nurse Midwife)
A person who assists women in childbirth
CNP (Certified Nurse Practitioner)
Nurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician
Cancer
See Oncology, Medical Oncology, Gynecologic Oncology, and Radiation Oncology
Cardiology or Cardiovascular Disease
Diagnosis and treatment of diseases of the heart and blood vessels
Chiropractic
Treatment that utilizes the relationship between the musculoskeletal structures and functions of the body, particularly of the spinal column and the nervous system
Critical Care Medicine
Health care provided to a critically ill patient during a medical emergency or crisis
DC (Doctor of Chiropractic)
See Chiropractic
DDS (Doctor of Dental Surgery)
See Dentistry
DO (Doctor of Osteopathy)
Diagnoses and treats diseases, injuries, and disorders for people of all ages; a physician who has had four years of premedical education in a college or university followed by four years of medical school (education includes training in musculoskeletal manipulation)
DPM (Doctor of Podiatric Medicine)
See Podiatry
Dentistry
Care and treatment of the teeth and gums
Dermatology
Diagnosis and treatment of diseases and disorders of the skin
Endocrinology, Diabetes, and Metabolism
Diagnosis and treatment of diseases and disorders of the endocrine glands (thyroid, pituitary, pancreas, ovaries, and testes), including diabetes
ENT (Ear, Nose, and Throat)
See Otolaryngology
Family Practice
Medical Doctors who diagnose and treat medical conditions for people of all ages, with an emphasis on family health problems
Gastroenterology
Diagnosis and treatment of diseases and disorders of the stomach, intestines, liver, and gallbladder
General Practice (GP)
Medical Doctors who diagnose and treat diseases, injuries, and disorders for people of all ages
Geriatric Medicine
Diagnosis and treatment of medical conditions in the elderly
Geriatric Physician (GER)
Medical Doctor providing comprehensive diagnosis, evaluation, and care for elderly individuals
Gynecologic Oncology
Diagnosis and treatment of cancers of the female reproductive organs, such as ovarian cancer, cervical cancer, and uterine cancer
Hematology
The treatment of diseases of the blood, spleen, and lymph glands
Infectious Disease
Diagnosis and treatment of complicated infections, including those associated with patients with reduced abilities of the immune system such as leukemia patients, organ transplant recipients, and HIV-related diseases
Internal Medicine (IM)
Medical Doctors who diagnose and treat diseases and disorders of the body for people over age 18; includes basic and preventive treatment and diagnosis, and treatment of acute and chronic illnesses
MD (Medical Doctor)
Physician who has had four years of premedical education in a college or university followed by four years of medical school
Maternal and Fetal Medicine
Treatment for patients with complicated pregnancy.
Medical Oncology
Diagnosis and treatment of the abnormal growth of tissue (cancer)
Neonatal Oncology
Care for high-risk infants, including pre-term and full-term infants with medical or surgical problems
Nephrology
Diagnosis and treatment of diseases and disorders of the kidneys
Neurology
Diagnosis and treatment of diseases and disorders of the nervous system
Neurosurgery
Surgical treatment of disorders and injuries of the brain and nervous system.
NP (Nurse Practitioner)
Nurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician
Nutrition
Treatment of various types of nutritional problems, such as obesity, nutrition support, and malnutrition; see providers under Endocrinology, Diabetes, and Metabolism, and Internal Medicine.
OD (Doctor of Optometry)
See Optometry
Obstetrics and Gynecology (OB/GYN)
Medical Doctors who diagnose and treat females and the female reproductive system, including management of care during pregnancy and childbirth
Occupational Medicine
Management of medical conditions in relation to motor skills
Occupational Therapy
Use of therapeutic activities in mental and physical disorders
Oncology
Diagnosis and treatment of tumors and cancer; see Medical Oncology, Gynecologic Oncology, and Radiation Oncology.
Ophthalmology
Examination, diagnosis, treatment, and management of diseases and disorders of the eye with appropriate medical and surgical procedures
Optometry
Examination, diagnosis, treatment, and management of diseases and disorders of the eye and visual system
Oral and Maxillofacial Surgery
Surgery to treat disorders of the gums, teeth, and mouth
Orthodontics
The use of devices (such as braces) to move teeth or adjust underlying bone
Orthopedic Surgery
Diagnosis, treatment, and repair of disorders involving the spine, bones, joints, and muscles
Otolaryngology or Ear, Nose, and Throat (ENT)
Diagnosis and treatment of diseases and disorders of the ear, nose, and throat
Pediatrician (PEDS)
Medical Doctors who diagnose and treat infants and children up to age 18
Pediatrics
Diagnosis and treatment of diseases of children and adolescents and general management of their health
Physical Medicine and Rehabilitation
Therapeutic use of physical medicine and equipment in the treatment of injury and disease
Physical Therapy
The use of exercise and physical activities to condition muscle and improve a patient’s level of activity
Physician Assistant (PA) or Physician Assistant – Certified (PA-C)
A health care professional who is licensed to provide patient education or evaluation and health care services; a physician assistant works under the supervision of a doctor to provide medical care
Plastic Surgery
Repair and restoration of external physical defects or trauma effects
Psychiatry/Psychology
Diagnosis and treatment of mental, addictive, and emotional disorders; see Behavioral Health
Podiatry
Diagnosis and treatment of diseases and injuries to the foot
Pulmonary Disease and Pulmonology
Diagnosis and treatment of diseases of the lungs and airways
Radiation Oncology
Medical use of radiation to destroy cancers
RN (Registered Nurse)
An individual trained to provide medical care under the supervision of a physician
Rheumatology
Diagnosis and treatment of diseases and disorders of the joints, muscles, bones, and tendons, such as arthritis and degenerative joint disease
Specialist
Physician who has had four years of premedical education in a college or university followed by four years of medical school, plus at least three years of residency in a specific area of medicine
Sports Medicine
Diagnosis and treatment of sports-related injuries with emphasis on prevention of injury and illness
Surgery
Operative treatment of internal and external diseases
Thoracic Surgery
Use of surgery to treat diseases of the heart and lungs
Urology
Diagnosis and treatment of diseases and disorders of the urinary system and adrenal glands
Vascular Surgery
Use of surgery to treat diseases of the blood vessels, including stroke and circulation problems