Terms to Know
What You Need to Know
It may seem like health care and health insurance have a language all their own. This glossary can help you better understand words commonly associated with this and other medical plans. Master them now, and you’ll be set up for success going forward.
Benefit year. The time period, usually the academic year, used to determine when you meet your annual deductible, benefit maximums, if any, and annual out-of-pocket limits.
Coinsurance. The slice of a medical service you’re responsible for. For example, you might pay 20% of the cost for a particular service, and the insurance company or plan will pick up the tab for the remaining 80%.
Coordination of benefits (COB). Applies to UC SHIP members who are covered by more than one health care plan. COB helps to ensure these students receive the benefits they are entitled to and prevent overpayment by either plan.
Copay (copayment). The flat fee you pay for covered services, usually due at the time you receive care. For example, you might pay a $15 copay to see a primary care doctor or specialist.
Coverage period. The period during which a student and their covered dependents are eligible for coverage and receive the benefits of their plan. Coverage periods align with the academic terms at each campus.
Deductible. The amount you have to pay toward medical costs before UC SHIP starts paying part of the bill.
Emergency. An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm or death.
Enrollment period. The period during which non-registered UC students can voluntarily enroll in UC SHIP. These periods typically begin 30 days before the start of the academic term and end 30 days after the first day of the academic term.
Explanation of Benefits (EOB). The explanation sent by the plan that shows how your benefits work for every doctor visit and service you receive. It includes how much UC SHIP pays and how much you owe, as well as how much of your annual deductible you’ve already paid for the year. EOBs are typically mailed to you by Anthem within six weeks after you or a provider submits a claim for payment.
Form 1095-B. The form sent by the IRS that verifies you were enrolled in a health care plan that qualifies as minimum essential coverage, as required by the Affordable Care Act.
Inpatient. A patient who is admitted to the hospital.
Maximum allowed amount. The total reimbursement payable under your plan for covered services you receive from network and out-of-network providers. It is the claims administrator’s payment toward the services billed by your provider, combined with any deductible or coinsurance you may owe. If you receive services from an out-of-network provider, the provider will bill you the difference, if any, between their charges and the maximum allowed amount.
Network/network providers/in-network providers. A group of health care providers and facilities — including doctors, hospitals and labs — that contract with your health care plan to provide services at negotiated discount rates. You’ll usually pay less when you use a network health care provider. UC SHIP contracts with Anthem Blue Cross to provide access to its extensive network of hospitals and providers, including UC Family facilities and provider groups.
Out-of-network/out-of-network providers. Health care professionals, hospitals, clinics and labs that do not belong to the Anthem Blue Cross Prudent Buyer PPO network. You’ll typically pay more, pay upfront, and file your own claim for reimbursement when you use out-of-network services.
Out-of-pocket maximum limit. The maximum amount of money you’ll have to pay for health care in a benefit year. After you meet the maximum, UC SHIP covers 100% of all eligible costs for the rest of the benefit year.
Period of coverage. The period of time during which your health is protected by UC SHIP.
Preferred provider organization (PPO). A group of medical or dental providers who contract with an insurance carrier to provide services for the plan member at reduced rates.
Qualifying life event (QLE). A change in your situation — like getting married, having a baby, or losing health coverage — that can make you eligible to enroll in UC SHIP outside the voluntary enrollment periods.
Referral. Authorization given by the student health center (SHC) for you to seek care outside the SHC for medically necessary services.