SBC Disclosure

Glossary reel Health Coverage me Medical Terms

• Glossary yeel e seleti mil ssogh na iit, nge saabw alongal iit elo lóll lista yeel. IIt me sessel kka lóll Glossary yeel nge amalall ebwe edukasion schagh nge emmwel e saabw wewe me iit kka lóll plano yeel me bwal health insurance policy. Bwal akkááw iisch kkei nge emmwel e saabw bwal wewee yááyál me faal policy me plano, nge policy me plano ekke maamaaw schagh. (Piipiiy yóómw Summary of Coverage reel infotmasion ngare ubwe tingór yóómw copial dokumentol policy me plano.)

• Mili kka e underlined na isch nge e sessel me lóll Glossary.

• P iipiiy page 6 reel example bwe ekke abwaari efaisul deductibles, coinsurance me out-of-pocket limits re tarabwaagho fengel.

Allowed Amount

Iyeel mas tómoghol óbwóss faal plano yeel reel mili kka e bwalabwal na setbisiol mééf. Ebwal ffai bwe “eligible expense”, “payment allowance”, me “negotiated rate”.

Ammwel kaay

Nge setbisiol sumwaay, ghilaas, me condision kka ewei bwe a tschow nge u nisisitai mil mwetekkai na setbisio, nge lau ese ghi tschow bwe ubwe ló Kuattol emergency na setbisio.

Appeal

Nge request bwe yóómw health insurer me ngare plano ebwe amweri desision la e asafali benefisio me ngare óbwóss (alongal me ngare eghus).

Balance Billing

Ngare tingór me reel yóómw provider óghówl mili kka ese bwalabwal na setbisio faal plano. Góósto yeel nge diferensial mila e ellet me allowed amount. Example, ngare óbwóssul provider nge $200 me allowed amount nge $110, iwe emmwel provider ebwe tingór llus la $90. Ssoghul schagh igha ngare u yááyá out-of-network provider, (non-preferred provider). Network provider (preferred provider) essemwel rebwe balance bill lugh reel mili kka a bwalabwal na setbisio.

Bwalabwal na setbisio

Nge setbisio kka yóómw plano ese óbwóssuw me bwalúw.

Claim

Nge tingór reel benefisio (me bwal óbwóssul mééfi na góósto) kka u fééri me ngare yaal tingór yóómw provider ngeeli yóómw health insurer pat plano reel setbisio kka u mengiiy bwe e bwalabwal.

Coinsurance

(See page 6 for a detailed example.)

Yaal plano e óbwóss

80%

Jane e óbwóss

20%

Yóómw óbwóss reel mili kka a bwalabwal na setbisio, re katkulai ngare percentage (example, 20%) reel mili kkewe e allowed amount na setbisio. Ubwe óbwóss coinsurance me naamwo meet na deductibles kka u dibii li. (Reel example, ngare health insurance, pat yóómw plano e bwalúw office visit reel $100 nge uwa óbwóssuw ló yóómw deductible, yóómw coinsurance reel 20% nge ebwe $20. Yóómw health insurance me ngare plano ebwe óbwóssuw alongal allowed amount.)

Complications of Pregnancy

Condisionul bwoobwo, méttagh, me layulaay ikka e nisisitai medical care bwe ebwe piilaay sumwaay bwe e te ghula nana me layuul. Sumwaayil lessor me emergency na operal uubw nge ese bwal complications of pregnancy.

Copayment

Nge óbwóssul (reel example, $15) mili kka e bwalabwal na setbisio, ngare u wa resibiiy setbesio (re bwal faingi bwe “copay”). Góósto yeel nge ebwal dependi reel meeta na setbisio.

Cost Sharing

Yóómw góósto reel setbisio kka e bwalabwal fáál plano yeel ikka ubwe óbwóssuw (eyoor igha re iira bwe out-of-pocket costs”). Akkááw examples reel cost sharing nge copayments, deductibles, me coinsurance. Cost sharing reel familiya nge góóstom, schóólimmom, me loomw reel deductibles me out-of-pocket costs ikka ubwe óbwóssuw me reel borosóómw. Akkááw góósto, ewei premiums, ammwuta kka ubwe óbwóssuw, me ngare reel góóstol plano ese bwalabwal me ese ffai bwe cost sharing.

Cost-sharing Reductions

Nge discounts kka e ribóówtiw méél akkááw setbisio faal plano me lóll Marketplace. Emmwel ubwe resibiiy discount ngare ulo faal akkááw na level, me ngare u afili bwe ubwe yááyá Silver level health plan me ngare u membrol federally-recognized tribe, ewei Alaska Native Claims Settlement Act na corporation.

(See page 6 for a detailed example.)

Yaal plano e óbwóss

0%

Jane e óbwóss

100%

D eductible
Nge góósto iye emmwel ubwe dibiili lóll tempoola (ngare yeew raagh) reel setbisio kkala e bwalabwal, antes de plano ebwe móghut le óbwóss. Eyoor deductible lóll alongal mili kka e bwalabwal na peiraagh me setbisio. Yeew na plano emmwel ebwe yoor yaal deductible ila e fil ngali yeew ngare grupul setbisio. Emmwel bwe yeew na plano eppwal yoor yaal separate na deductibles. (Example, ngare yóómw deductible nge $1,000, yóómw plano e saabw óbwóss esta ki uwa ghula yóómw $1,000 na deductible reel mili kka e bwalabwal na submission.

Diagnostic Test

Test kkaal nge amalall ebwe ghuta sumwaayum. Ngare example, x-ray bwe ebwe test li ngare eyoor bwuulull schuu.

Emergency Medical Condition

Nge sumwaay, ghiilas, me symtumol (bwal métagh tumógh) mil tschow na sumwaay kka ebwe ngau ngare use mwuttekai le ghuta pilipilil. Ngare use ghuta kkei piilipilill sumwaay kkei nge emmwel ubwe paringi mile kkei: 1) Yóómw mééf nge ebwe ghi piligro; me 2) Ebwe yoor sirioso problemóm reel ilighiimw; 3) Ebwe ffeir yóómw organ me lóll ilighiimw.

Emergency na waawa

Setbisiol ambulan ngare reel emergency medical condition. Mili kka emergency na waawa nge reel yaang, falúw me leset. Emmwel bwe yóómw plano e saabw bwalúw alongal emergency na waawa, me ngare ebwe bwalúw eghus me reel akkááw.

Formulary

Listal séfay kka yóómw plano e bwalúw. Lista yeel nge emmwel ebwe abwaari góóstom reel sáfey. Yóómw plano emmwel eppwal issali sáfey wóól cost-sharing levels ngare téél. Ngare example, emmwel bwe formulary ebwe ayoora generic na séfay me ngare téélil séfay me óbwóssul cost-sharing kkei me reel téétélil.

Grievance

Nge complaint iye u angeli yóómw health insurer me ngare plano.

Health Insurance

Nge contrata iye health insurer ebwe óbwóssuw alongal góóstol malawóóm faal mille premium. Bwal yeew iital millel nge “policy” me ngare “plano.”

Home Health Care

Setbisiol mééf me peiragh kka yóómw dokto e odali. Setbisio kke nge emmwel bwe reel finmeera, therapists, social workers, me ngare akkááschei mal lisensia na providers. Home health care nge ese tolong, non-medical tasks kka ewei ffeerul mwongo, aghasaghas, me ubwe draiba ghareeta.

Hospitalization

Nge setbisio kka igha ubwe lolóó spitóód. Akkááw plano nge considerai yóómw lolóó yeew bongil ngare outpatient, saabw inpatient care.

Hospital Outpatient Care

Nge setbisiol spitóód kkewe ngare use bwal lolóó.

In-network Coinsurance

Yóómw óbwóss (example, 20%) reel allowed amount kka a bwalúw setbisio kkei. Yóómw óbwóssul setbisio kka elo lóll in-network nge e ppelleló.

In-network Copayment

Eyoor góósto iye (example, $15) óbwóssul mili kka e bwalabwal na setbisio me reel yóómw providers ikka re ppwol fengel me yóómw health insurance me ngare plano. In-network copayments nge eppelleló óbwóssul mwal out-of-network copayments.

Kuattol emergency na setbisio

Nge setbisio kka faal emergency medical condition nge ebwe alisugh me reel emergency medical condition bwe uute mas ngau ló. Setbisio kkei nge emmwel ebwe yoor me reel mili kka e lisensia na emergency room me akkááw bwulei igha eyoor emergency medical conditions

Marketplace

Lóll marketplace nge re lo alongeer health insurance ikka yeel, yóómw familiya, me bisnes kkei au bwe akkábwung óówtol ymi plano; au bwe apply me resibiiy yaami alilis reel fainansiat faal premiums me cost sharing segun reel óbwóssum; me ubwe affili yóómw plano. Bwal yeew iital milleel nge “Exchange”. Mille Marketplace nge e ffáátábw faal states me lóll akkááw me bwal fáál federód reel akkááw na states. Me loll akkááw states, nge Marketplace ebwal alisiir schóó kka fáál akkááw na programa, me bwal Medicaid me Children Health Insurance Program (CHIP). Mili kkei nge re lo online, reel tilifon, me in-person.

Maximum Out-of-pocket Limit

Nge óbwóssul yeew raagh federód e isali bwe ila llangal aeschei aramas me familiya cost sharing durantil plano yeel reel mili kka e bwalabwal na in-network setbisio. Mili kkaal nge e apply lóll ssogh na plano ngare insurance. Góósto yeel nge emmwel ebwe tschow ló mmwal out-of-pocket limits kkemu e lo lóll plano.

Medically Necessary

Setbisio me peiráágh kka e nisisita bwe ebwe piilaay, diagnose, séfaya sumwaay, ghilaas, condisision, ghoos, me yaal symptoms bwal ammwelil mééf kka e ghuula standards of medicine.

Mil lléégh peiráághil sáfey

Ramenta me peiráágh kka provider e odali bwe rebwe yaali alongal raal me bwungiyal tempoo. DME emmwel ebwe ayoora ngare peiráághil oxygen, wheelchairs, me bóóston.

Minimum Essential Coverage

Mille minimum essential coverage nge plano me health insurance ikka si schuungi me lóll Marketplace me akkááw na market policies, Medicare, Medicaid, CHIP, TRICARE, me akkááw bwalabwal. Ngare u eligible reel akkááw minimum essential coverage, emmwel bwe u saabw eligible reel premium tax credit.

Minimum Value Standard

Yeew standard ebwe appeew percent nil mili kka e bwalabwal na góósto faal plano. Ngare re ngaléégh employer plano iye ebwe óbwóss 60% reel alongal allowed costs faal benefisio, plano yeel nge ekke ngaléégh minimum value nge emmwel bwe u saabw qualify reel premium tax credits me cost-sharing reductions bwe ubwe amééw plano me reel Marketplace.

Network

Nge fasilidat, providers me suppliers kka yóómw health insurer me ngare plano re ppwol bwe rebwe ayoora setbisiol mééf kkei.

Network Provider (Preferred Provider)

Nge provider iye e ppwol me yóómw health insurer me ngare plano, bwe rebwe ayoora setbisio kkei bwe yaar membrol plano yeel. Ubwe óbwóss eghus ngare u weri provider me lóll network. Ebwal ffai bwe “preferred provider” bwal “participating provider.”

Orthotics and Prosthetics

Nge peschee, paay, sóghurrumw me brace sil orongómw, mil ffeer na peschee, paay me sóbweilum, me mil ffeer na túút mweril operasion. Setbisio kkei nge: adjustment, repairs, me replacements kka e nesisita bwe reel e ffeer, yááyá, malingu me yaal lliwel condisionul mal sumwaay.

Out-of-network Coinsurance

Yóómw óbwóss (example, 40%) faal allowed amount reel mil bwalabwal na setbisiol mééf reel providers kkewe re se ppwol me yóómw health insurance me plano. E tschow ló óbwóssul out-of-network coinsurance mmwal in-network coinsurance.

Out-of-network Copayment

Eyoor góósto iye (example, $30) u óbwóssuw reel mil bwalabwal na setbisio me reel yóómw providers kkewe re se ppwol me yóómw health insurance me ngare plano. Out-of-network copayments nge e tschow ló mmwal
in-network copayments.

Out-of-network Provider (Non-Preferred Provider)

Nge provider iye ese ppwol me yóómw plano bwe ebwe ayoora setbisio. Ngare yóómw plano e bwalúw out-of-network services, iwe ebwe tschow ló óbwóssul mmwal preferred provider. Yóómw policy ebwe aghuleey ngaluugh meeta góósto kkei. Bwal iital nge “non-preferred” bwal “non-participating” nge saabw “out-of-network provider.”

Out-of-pocket Limit

(See page 6 for a detailed example.)

Jane e óbwóss

0%

Yaal plano e óbwóss

100%

N ge mille mas tumógh ubwe óbwóssuw (lóll yeew ráágh) reel mili kka e bwalabwal na setbisio. Ngare uwa óbwóssuw ló millel, plano ebwe le óbwóssuw ló 100% reel allowed amount. Limit yeel ebwe alisuugh reel yóómw plano li góóstom. Limit yeel nge ese kke atolongow premium, balance-billed charges, me ngare góósto kka ese bwalabwal faal yóómw plano. Akkááw plano re se páángi alongal yóómw copayments, deductibles, coinsurance, out-of-network payments me akkááw góósto reel limit yeel.

Physician Services

Setbisio kka mal lisensia na dokto, doktol schuu, re ayoora me coordinate li.

Pilipiliil sumwaay

Milleel nge routine health care, me screenings, check-ups, me counseling bwe ebwe piileey me ngare schuungi sumwaay me akkááw na problemal mééfi.

Plano

Yóómw bwalabwal me reel yóómw plano (individual plan) me bwal reel yóómw aangang, union me meeta na grupu (employer group plan) ila e ayoora bwalabwal faal akkááw na health care costs. Bwal iital mili kkei nge “health insurance plan,” “policy,” “health insurance policy," me “health insurance.”

Preauthorization

Nge decision me reel yóómw health insurer me ngare

plano bwe setbisiol mééf, yóómw planol sáfey,

prescription drug me durable medical equipment (DME)

nge e medically necessary.

Eyoor igha re faingi bwe “prior authorization,” prior

approval,” me “precertification.” Yóómw health

insurance me ngare plano emmwel ubwe nisisitai

preauthorization reel akkááw setbisio, fuerra lóll

emergency. Preauthorization nge saabw promesa

bwe yóómw health insurance me ngare plano ebwe

óbwóssuw góósto kkei.

Premium

Nge óbwóssul yóómw health insurance me ngare plano. Yeel bwal emmwel bwe óómwum au ghal óbwóssuw milleel lóll maram, quarterly, me ngare ráágh.

Premium Tax Credits

Alilisil fainansiat la e ribówtiw yóómw taxes bwe yeel me yóómw familiya aubwe mmwel le óbwóssuw yaami health insurance. Emmwel bwe ubwe buughi alilis yeel ngare u amééw yóómw health insurance me reel Marketplace nge óbwóssum e sóóssól. Iwe emmwel ubwe advance li óbwússul tax credit yeel bwe ebwe ribówtiw yóómw premium lóll maram.

Prescription Drug Coverage

Bwalabwal kka faal plano ila e scheelugh reel óbwóssul prescription drugs. Ngare yóómw plano formulary e yááyá “tiers” (levels), iwe re óschuuw prescription drugs reel yaal type me góóstol. Mila ubwe óbwóssuw faal cost sharing nge e saabw weewe reel kada “tier” reel mil bwalabwal na prescription drugs.

Prescription Drugs

Séfay me amweliil ilighisch kka e nisisita prescription me reel dokto.

Primary Care Physician

Nge sóusáfey me ngare dokto, (doktol schuu), me akkááschei kka re iseisiwow me ammwela setbisiol mééf kkei ngeluugh.

Primary Care Provider

Nge sóuséfay me dokto, me ngare (doktol schuu), finmeera, clinical na finmeera, yaal dokto assistant ikka re lisensiar bwe rebwe alilis faal state law me kkapasal plano, bwe rebwe ayoora, ammwela, me alisuugh reel alongal setbsio kka eyoor.

Provider

Nge aramas me ngare fasilidat iye e ayoora setbisio kkei. Akkááw example provider nge dokto, finmeera, chiropractor, physician assistant, spitóód, leeliyeel opera, me imwal ammwel, me rehabilitation center. Plano yeel nge emmwel ebwe nisisitai provider bwe ebwe lisensia, certified, me ebwe accredited faal state law.

Reconstructive Surgery

Nge opera me yaal follow-up séfay bwele ebwe aweela me ngare aghatschuuwló ppatiil ilighimw bwe reel birth defects, aksidenti, ghilaas, me ngare akkááw medical conditions.

Referral

Nge mil isch na order me reel yóómw primary care provider bwe ubwe weri specialist reel meeta na setbisio. Lóll ssoghul health maintenance organization (HMO), u nisisitai referral bwe ubwe yááyá setbisio me reel akkááschei ffééra yóómw primary care provider. Ngare u se ghomwal buughi referral, plano emmwel bwe e saabw óbwóssuw setbisio.

Setbisiol amaamaa

Setbisio kkei nge ebwe aghatschiuw me ebwe sappotai schóó kkewe rebwe le méé me yaar familiya.

Setbisiol Habilitation

Nge setbisio kka e scheeli aramas bwe ebwe issali, ghukkule me ebwe aghatschiiw ló yóómw skills me yóómw lollo. Examples nge yaar oleghat therapy bwe rebwe akkabwung fééragh me kkapas. Mili kkal na setbisio nge emmwel bwe ebwe physical ngare occupational therapy, speech-language pathology, me akkááw na setbisio kka yaar mal sumwaay me lóll inpatient me outpatient na manera.

Setbisiol Rehabilitation

Nge setbisiol ammwel kka e scheeli aramas bwe ebwe isali, buughi sefaliiy, me ngare aghatschuuló malawóóm bwe igha u sumwaay, meetegh me disabled. Setbisio kkei nge physical me occupational therapy, speech-language pathology, me psychiatric setbisio lóll akkááw inpatient me ngare outpatient settings.

Screening

Nge yeew klasiil screening loll pilipiliilkuat sumwaay la e ayoora tests me exams bwe ebwe ghuuta meeta, ngare iye esóór symptoms, signs, me history yóómw mééf.

Skilled Nursing Care

Setbisio kka mal lisensia na finmeera e feeri lóll iimwóm me ngare lóll nursing home. Skilled nursing care nge ese weewe me “skilled care services,” mili kkewe yaar angang therapists me technicians (saabw finmeera) lóll iimw me nursing home.

Specialist

Nge provider iye yeew ló schagh yaal ammwelil séfay me ngare grupul mal sumwaay nge ebwe ghuuta, maneyaali, piilaay, me séfeeya akkaáw symptoms me conditions.

Specialty Drug

Nge yeew klasiil prescription drug la e nisisitai special handling, me ongoing monitoring, me assessment me reer health care professionals me ngare igha e weires ffééril. Specialty drugs nge ii mille eghi tschow lóll formulary.

UCR (Usual, Customary and Reasonable)

Ikkei góóstol setbisio me lóll luugat nge e awewe wóól meeta kka providers re ghal tingór bwe óbwóssuur reel mil wewee na setbisio. Góósto iye UCR nge rebwe bwal ghal yááli bwe ebwe detetminai allowed amount.

Efaisul Yeel me Yóómw Insurer Au Bwe Yááyá Fengal Góósto Kkei - Example

Jane’s Plan Deductible: $1,500

Coinsurance: 20%

Out-of-Pocket Limit: $5,000

Eneero 1st Bweletaal Tempol Bwalubwal

Decembre 31st Órorosol Tempol Bwalubwal

Jane e óbwóss

100%

Yaal plano e óbwóss

0%

Jane esaal ghula yaal $1,500 deductible.

Yaal plano esaal mmwel ebwe óbwóss.

Office visit costs: $125

Jane ebwe óbwóss: $125

Yaal plan ebwe óbwóss: $0

Jane e óbwóss

20%

Yaal plano e óbwóss

80%

Jane a ghula yaal $1,500 deductible, coinsurance abweel.

Jane e weri dokto faal akkááw nge aa óbwóss $1,500, nge aa ghula yaal deductible. Iwe yaal plano ebwe óbwóssuw akkááw góósto reel yaal next visit.

Office visit costs: $125

Jane ebwe óbwóss:

20% reel $125 = $25.

Yaal plano ebwe óbwóss:

80% reel $125 = $100.

Jane e óbwóss

0%

Yaal plano e óbwóss

100%

Jane a ghula yaal $5,000
out-of-pocket limit.

Jane aa faal ssogh yaal weri dokto nge aa óbwóssuw ló $5,000 lóll alongal. Yaal plano ebwe óbwóssuw alongal góóstol reel mil bwalabwal na setbisio lóll ráágh yeel.

Office visit cost: $125

Jane ebwe óbwóss: $0

Yaal plano ebwe óbwóss: $125

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.02 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

(OMB control number: 0938-1146/Expiration date: 05/31/2026)

Glossary of Health Coverage and Medical Terms Page 3 of 4