Tyson Foods

Important terms that every member should know:

Appeal

This is a request for your insurance plan to reconsider a claim that has been denied. You can also appeal a prior authorization denial.

Authorization

(Also: Pre-Authorization or Prior-Authorization)

These are an agreement in advance from your insurance plan to pay for a service or medication. Usually a prior authorization requires your doctor to submit paperwork to your insurance plan explaining why you need a service or medication. If the prior authorization is granted, that means your insurance plan has agreed to pay for the service or medication. (You may still owe a copay or other cost out of pocket.) If the prior authorization is denied, that means your insurance does not agree to pay for the service or medication. You can submit an appeal if your prior authorization is denied.

Carrier

A carrier is another name for an insurance company.

Claim (also called “insurance claim”)

A request for your insurance plan to pay for a health service that you have received. If a claim is approved, your insurance plan will pay for the health service. You may still owe a copay, coinsurance or other cost out of pocket even if a claim is approved. If a claim is denied, your health insurance plan will not pay for the health service and you must pay the full cost to the provider yourself.

Copay

The amount that you must pay up-front to receive a health care service or medication. A copay is usually a set amount of money—for example, your copay to see your primary care doctor might be $20. The copay amount is determined by your insurance plan. The copayment is usually different depending on the type of service or medication you receive. For example, the copay to see your primary care doctor is usually lower than the copay to visit an urgent care center, and the copay for a generic medication is usually lower than the copay for a name-brand medication.

Co-insurance

The amount that you must pay to receive a health care service or medication. A co-insurance amount is usually a percentage of the total cost of the service or medication–for example, your coinsurance for a surgery might be 20% of the total surgery cost. The co-insurance amount is determined by your insurance plan.

Deductible

The amount that you must pay out of pocket before your health insurance plan begins paying for certain services. If you have paid the full deductible amount out of pocket, you have “met your deductible.” Some services are “subject to deductible,” meaning that you must meet your deductible before a plan will begin to pay for those services. Some services are “not subject to deductible,” meaning that your plan will begin to pay for those services even if you have not met your deductible. If you have a maximum out of pocket amount that is higher than your deductible, you may still pay some costs until you meet your maximum out of pocket amount.

EMO

Expert Medical Opinion is a virtual second opinion given by an expert in the field. A member will request an EMO for a specific condition, a clinician will ask questions regarding past treatment, concerns, questions, expectations, etc. and then a full collection of pertinent medical records will be done by the Records Specialists. Once record collection is complete they will be sent to the expert who treats the condition, the expert will review the records and the member’s questions and deliver a written second opinion to the member. 

EPO

Exclusive Provider Organization (EPO) plan is a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency). 

Formulary (see Drug Formulary)

A list of drugs covered by the health plan. These drugs can be both generic and brand-name prescription drugs.

FSA (Flexible Savings Account or Flexible Spending Account)

A special account that is offered by your employer to allow you to set aside money for medical expenses without paying taxes on that money. FSA money is usually “use it or lose it,” meaning that you must spend the money you have saved before the end of your health insurance plan year.

Generic Medication

A medication that can be manufactured by many companies. These medications tend to be less expensive than name brand medications. Generic medications are just as effective as name brand medications and are legally required to have the same active ingredients as the name brand versions.

HDHP (High Deductible Health Plan)

HDHP’s have higher deductibles than most health plans.

Health Insurance

In a nutshell, insurance is a contract that requires the company that insures you to pay some or all of your health care costs in exchange for your monthly payments. 

Health Plan

Your health plan is the specific insurance plan you choose, and will have specific doctors and providers in the network who can take your insurance. 

HMO

Health Maintenance Organization, a type of health insurance plan with limited coverage. An HMO may require you to live or work in its service area to be eligible for coverage and it generally won’t cover out-of-network care except in an emergency. (www.healthcare.gov)

HSA (Health Savings Account)

A Health Savings Account is a tax free bank account connected to a High Deductible Health Plan to help offset the cost of that higher deductible. You can use the account like you would a personal checking or savings account, to pay for eligible medical, dental and vision expenses throughout the year. In some instances, your employer will contribute funds to this account as well but you’re also able to set aside funds into the account each pay period up to the maximum amount allowed by the IRS. 

In-Network

Providers who are “in-network” for your plan have entered into an agreement with your health insurance plan. The health insurance plan promises to pay a certain amount to the provider for services that are provided to patients. The provider promises to accept the amount that the health insurance plan pays and not charge the patient additional fees. Seeing an in-network provider usually means that you will pay the lowest cost for services. Some health insurance plans will not pay anything for services that are provided by “out-of-network” providers.

Name brand medication

A medication that is only manufactured by one company. These medications tend to be more expensive than generic medications. After a certain period of time, the company that makes a name brand medication no longer has the exclusive right to make that medication, and other companies can make generic versions of the medication.

Out-of-Network

Providers who are “out-of-network” for your plan have not entered into an agreement with your health insurance plan. Seeing an out-of-network provider usually means that you will pay the highest cost for services. Some health insurance plans will not pay anything for services that are provided by “out-of-network” providers, meaning that you will pay the full cost of services out of pocket.

Out-of-pocket maximum (also called “maximum out-of-pocket amount”)

Your out-of-pocket maximum is the most you will spend in a calendar year for your and your dependents medical care. This is above and beyond your deductible for the year. Once you hit your out of pocket maximum, insurance covers all of your medical care costs for the remainder of that plan year.

PPO (Preferred Provider Organization) 

A type of health plan where you pay less for going to providers in the plan’s network. In this situation, you can still go to doctors, hospitals, and providers outside of the network without a referral but there will be an additional cost. 

Premium

The amount that you pay every month to continue to have coverage through your health insurance plan. If you receive your health insurance through an employer, this amount is usually taken directly out of your paycheck. If you stop paying your premium, your health insurance plan will drop your coverage, and you will be uninsured.

Provider

A doctor, nurse practitioner, pharmacist, therapist, or other type of health care worker who provides health care services to you.