Glossary

Accountable Care Organization (ACO)
A partnership between doctors, hospitals and a health plan to bring you more coordinated care.

Affordable Care Act
The comprehensive healthcare reform law enacted in March 2010 (sometimes known as ACA or “Obamacare”). ACA plans are sold on the Health Insurance Marketplace that each state has.

Allowed amount
The maximum amount the plan will pay for a covered healthcare service. 

Annual Enrollment Period (AEP)
Every year, Medicare’s open enrollment period is October 15 through December 7. During this time, people with Medicare can change their Medicare health plans and prescription drug coverage for the following year to better meet their needs.

Annual Notice of Change
A document that your health insurance plan sends to you each year, usually in the fall. This notice details any changes in the plan’s costs, coverage, or service area that will take effect the following January.

Appeal
A request to review a decision made about a member's healthcare.

Authorized representative
Someone who you choose to act on your behalf with your health plan, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.

Behavioral health
Generally refers to mental health and substance use disorders, but can include any emotions or behaviors that impact your wellbeing.

Behavioral health providers
Doctors or therapists who help people with mental health or substance use disorder.

Beneficiary
A person who is eligible to receive benefits from an insurance policy or health plan. May also be called enrollee or member.

Benefits
The healthcare items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. There may still be costs for covered benefits.

Brand name (non-preferred) drug
A drug sold by a drug company under a specific name or trademark that is protected by a patent.

Bronze health plan
One of 4 plan categories (also known as “metal levels”) in the Health Insurance Marketplace®. Bronze plans usually have the lowest monthly premiums but the highest costs when you get care. They can be a good choice if you usually use few medical services and mostly want protection from very high costs if you get seriously sick or injured.

Carelon Behavioral Health
Carelon is an organization contracted by WellSense to administer the plan’s mental health and substance use disorder benefits.

Care management
 A patient-centered approach to healthcare that coordinates and manages the comprehensive healthcare needs of individuals, especially those with chronic conditions or complex medical needs.

Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace. For more information, visit cms.gov.

Claim
A request for payment from your doctor to your health insurer in order to get paid for items or services that should be covered.

Clarity plan
WellSense health plans for individual and families in Massachusetts. They include all the benefits required by the Affordable Care Act and the Massachusetts Health Reform Act. These plans were previously known as Qualified Health Plans.  

Coinsurance
Your share of the costs of a covered healthcare service. This is a percent of the allowed amount for that service.

ConnectorCare
ConnectorCare plans are subsidized Clarity plans that provide healthcare discounts to members who qualify. These plans have low monthly premiums, low co-pays, and no deductibles. Eligibility is determined by the MA Health Connector based on income level.

Continuity of care
A health plan’s obligation to ensure members receive continued care during a transition such as a departure of a doctor from the health plan’s network.

Copayment/copay
A fixed amount you pay for a covered healthcare service.

Cornerstone Health Solutions
WellSense utilizes uses Cornerstone’s mail order pharmacy to provide our members a home delivery mail service option for their medications.

Cost sharing
Your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called out-of-pocket costs). Some examples of cost sharing are copayments, deductibles, and coinsurance. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan doesn't cover usually aren't considered cost sharing.

Coverage
The range of medical services and treatments that your health insurance plan agrees to pay for.

Covered services
The medical services that your insurance will pay for.

Deductible
The amount you pay for covered healthcare services before your insurance plan starts to pay.

Department of Health and Human Services (DHHS)
The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP). For more information, visit hhs.gov.

Dependent
A child or other individual that is placed under a primary insurance policy holder’s (known as the subscriber) insurance policy.

D-SNP or dual coverage
Refers to a Dual Special Needs Plan, a type of health insurance plan for individuals who qualify for both Medicare and Medicaid. These plans offer combined benefits of both programs, often including additional services and supports tailored to the unique health needs of dual-eligible individuals.

Durable medical equipment (DME)
Equipment and supplies ordered by a healthcare provider for everyday or extended use. DME may include: oxygen equipment, wheelchairs, crutches and diabetes testing supplies.

Eligibility
Whether you meet the requirements to enroll in a health insurance plan. It often involves factors like age, income, employment status, or health condition. Being eligible means you qualify to receive health insurance benefits under a specific plan.

Emergency room care / emergency services
Services to check for an emergency medical condition. These services may be provided in a licensed hospital's emergency room or other place that provides care for emergency medical conditions.

Enrollment Assisters
People who are trained to help you understand and sign up for a Health Connector plan. They can help you for free.

Evidence of Coverage (EOC)
A document that serves as a contract between the member and the insurance company, detailing the healthcare benefits that are covered under the member's specific insurance plan

Exemption
A special allowance that releases you from a rule or requirement. In health insurance, this could mean not having to follow certain guidelines or being excused from specific fees or costs under particular circumstances. For instance, if a medical condition or financial hardship prevents you from meeting a health plan's standard requirements, you might qualify for an exemption.

Exception
 A special allowance or permission for something that is different from the usual rules or guidelines. This term is used when your health plan makes an exception to cover a service or medication that is not typically covered, or to use a provider outside of the standard network.

Exchange
Another term for the Health Insurance Marketplace®, a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance.
The Marketplace is accessible through websites, call centers, and in-person assistance.

Excluded services
Services that your health insurance plan does not cover.

Explanation of Benefits (EOB)
A statement from your insurance company after you receive medical services, explaining what was covered and what you might owe.

ExpressScripts
WellSense contracts with Express Scripts. This is the plan’s pharmacy benefits manager. Express Scripts manages your prescription drug benefit. 

Extra benefits
Additional benefits your health plan offers.

Extra Help (Medicare Part D)
A federal program designed to assist individuals with limited income and resources in paying for Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. This program is particularly beneficial for those who need financial support to cover their medication expenses.

Fixed enrollment period
After you choose a plan, there's a time called a fixed enrollment period when you can't change to a new plan until the next plan selection period, except for certain reasons.

Flexible Spending Account (FSA)
A pre-tax account you put money into that you use to pay for certain out-of-pocket healthcare costs.

Formulary (list of covered drugs)
A list of prescription drugs covered by a health plan.

Generic medication
A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

Gold health plan
One of 4 health plan categories (or “metal levels”) in the Health Insurance Marketplace®. Gold plans usually have higher monthly premiums but lower costs when you get care. Gold may be a good choice if you use a lot of medical services or would rather pay more up front and know that you’ll pay less when you get care.

Grace period
A short period — usually 3 months — after your monthly health insurance premium payment is due. Paying all owed premiums during the grace period will keep your health coverage intact.

Grievance
 A complaint that you communicate to your health insurer or plan.

Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Health Savings Account (HSA)
A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses.

HIPAA
 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.

Hospice services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. Some plans may consider an overnight stay for observation as outpatient care instead of inpatient care.

Individual responsibility requirement
Sometimes called the individual mandate, the duty you may have to be enrolled in health coverage that provides minimum essential coverage. If you don't have minimum essential coverage, you may have to pay a penalty when you file your federal income tax return unless you qualify for a health coverage exemption. This varies from state to state.

Initial Enrollment Period
When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. If you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

In-network coinsurance
Your share (for example, 20%) of the allowed amount for covered healthcare services. Your share is usually lower for in-network covered services.

In-network copayment
A fixed amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

In-network provider
A healthcare professional, clinic, or hospital that has an agreement with your health plan to provide services to its members.

Inpatient care
Healthcare that you get when you're admitted as an inpatient to a healthcare facility, like a hospital or skilled nursing facility.

Long-term (care) services and supports (LTSS)
These are services that help people with disabilities or long-term illnesses with daily activities over a long period.

MA Health Connector
An independent public authority that offers private insurance to individuals and families in Massachusetts.

Mail order pharmacy
A service that delivers your prescriptions directly to your home. This convenient option allows you to receive medications through the mail, often in larger quantities, and can be especially helpful for managing long-term medications.

Managed Care Organization (MCO)
A network of doctors, hospitals and other healthcare providers, who utilize managed care as their model to keep the quality of care high while limiting costs.

Marketplace
A service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance.

MassHealth
MassHealth is Massachusetts' Medicaid and Children's Health Insurance Program (CHIP). It provides comprehensive health insurance coverage to eligible Massachusetts residents, including families, children and people with disabilities.

Medicaid
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels.

Medical/Utilization review
The process by which insurers review the necessity of medical care and procedures to determine if they will be covered.

Medically necessary
Healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Medicare
A federal health insurance program for people who are 65 or older and certain younger people with disabilities.

Medicare Advantage
Also known as Medicare Part C, a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage.

Medicare Advantage open enrollment
If you’re enrolled in a Medicare Advantage plan and would like to make a one-time plan change, you can do so during the Medicare Advantage Open Enrollment Period. Between Jan. 1 and March 31, Medicare Advantage members can make a one-time change to another Medicare Advantage plan or return to Original Medicare. Coverage begins the first of the month following the month you make the change (i.e. plan change made Jan. 1, so new coverage would begin Feb. 1).

Medicare Part D
A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage.

“Medigap”(Medicare Supplement Insurance) policy
Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

Member
If you have a WellSense plan, you are a member.

Member handbook
A document that tells you how your health plan works, what it pays for and what costs you might have to pay.

Member ID card
An identification card that shows you are part of the health plan. You will need it when you go to the doctor or pharmacy.

Member portal
A secure online space where you can manage your health plan and member details. Here, you can view your coverage information, find healthcare providers, check your health records, access benefit updates, and complete important health assessments. The portal offers a convenient way to stay informed and engaged with your health plan from anywhere, at any time.

Member Services
A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals.

Mom's Meals
A meal delivery service included with some of our plans offering a wide variety of home-delivered meals tailored to meet specific dietary needs. With options like heart-friendly, diabetes-friendly, gluten-free, and vegetarian meals, they provide convenient, nourishing meals right to your doorstep. Each meal is designed to be easy to prepare, ensuring access to healthy food choices for individuals managing specific health conditions or dietary preferences.

Open Enrollment Period
The yearly period when people can enroll in a health insurance plan.

Original Medicare
The traditional Medicare program provided by the federal government. It includes Medicare Part A, which covers hospital insurance, and Medicare Part B, which covers medical insurance.

Out-of-network
Doctors, hospitals, or other healthcare providers who do not have a contract with your insurance plan. If you receive care from an out-of-network provider, your insurance may not cover the cost, or it may cover a smaller portion than it would for in-network providers, potentially leading to higher out-of-pocket expenses for you.

Out-of-network coinsurance
Your share (for example, 40%) of the allowed amount for covered healthcare services to providers who don't contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

Out-of-network copayment
A fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Out-of-Network provider
A healthcare professional, clinic, or hospital that does not have a contract with your health plan. You will usually pay more for services received from these providers.

Out-of-pocket costs/expenses
Your expenses for medical care that aren't reimbursed by insurance, including deductibles, coinsurance, and copays for covered services plus all costs for services that aren't covered.

Out-of-pocket maximum/limit
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.

Outpatient care
Care, typically at a hospital, which usually doesn't require an overnight stay.

Over-the-counter (OTC) drugs 
Medicines or health products that you can buy without a prescription from a healthcare provider.

Over-the-counter (OTC) card
A special type of debit card provided to some health plan members. It can be used to purchase approved health and wellness items like medications, first aid supplies, and other qualifying products at participating stores, online or over the phone.

Plan (health plan)
Health coverage issued to you directly (individual plan) or through an employer, union or other group sponsor (employer group plan) that provides coverage for certain healthcare costs. Also called health insurance plan, policy, health insurance policy or health insurance.

Plan Selection Period
This is the time when you can choose to stay with your plan or change to a new one.

Platinum health plan
One of 4 categories (or “metal levels”) of Health Insurance Marketplace® plans. Platinum plans usually have the highest monthly premiums of any plan category but pay the least when you get medical care. They may work well if you expect to use a great deal of healthcare and would rather pay a higher premium and know nearly all other costs are covered.

Policyholder
The policyholder is often the person insured by the policy, but they can also buy and maintain a policy for someone else, like a family member.

Pre-existing condition
A health condition or a medical problem you have before you get or change insurance plans. You cannot be denied coverage because of a pre-existing condition.

Preferred drug
A medication that has been evaluated for its effectiveness, safety, and cost, and is recommended by a health plan. These drugs are typically the first choice for treating a particular health condition. They are included in a preferred list, often known as a formulary, and are usually more cost-effective for members.

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

Premium
The amount you pay for your health insurance every month.

Prescription drug coverage
Coverage under a plan that helps pay for prescription drugs. If the plan's formulary uses tiers (levels), prescription drugs are grouped together by type or cost. The amount you'll pay in cost sharing will be different for each tier of covered prescription drugs.

Prescription drugs
Drugs and medications that by law require a prescription.

Preventive dare/preventive services
Routine healthcare, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems.

Price transparency
The process of providing clear, accessible information about the costs of medical services and treatments. This allows patients to understand and compare prices for different healthcare options, helping them make informed decisions about their care.

Primary care provider (PCP)
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of healthcare services.

Prior authorization/preauthorization
A requirement to get approval from your health plan before you receive certain healthcare services or medications, to ensure the service is covered by your plan.

Protected health information (PHI)
Any information in the medical record or designated record set that can be used to identify an individual and that was created, used or disclosed in the course of providing a healthcare service such as diagnosis or treatment.

Provider
A term used for health professionals who provide healthcare services.

Qualified Health Plan (QHP)
Health plans with all the benefits required by the Affordable Care Act and the Massachusetts Health Reform Act that have been approved by the Massachusetts Health Connector. WellSense Qualified Health Plans were renamed to Clarity plans in 2024.

Qualifying life event
A change in your situation, like getting married, having a baby, or losing health coverage, that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.

Quantity limitation program
This program ensures the safe and appropriate use of some drugs by limiting the amount of the drug that we cover per prescription or for a defined period of time.

Redetermination
This is the process of reviewing and confirming your eligibility for health insurance coverage. It usually happens annually to ensure that your current health plan still meets your needs and that you continue to qualify for the plan based on factors like income and family size.

Referral
A written order from your primary care doctor for you to see a specialist or get certain medical services.

Reimbursement
The process where your insurance company pays you back for out-of-pocket expenses you've incurred for covered medical services or prescriptions. This typically happens when you've paid the full cost upfront and submit a claim to your insurer for the amount to be refunded according to your plan's coverage.

Schedule of Benefits
This document provides a detailed list of specific benefits covered under a health insurance plan.

Senior Care Options
A comprehensive health plan designed specifically for older adults ages 65 and older. It may combine both Medicare and Medicaid benefits into one coordinated program. Senior Care Options offers a wide range of healthcare services, including medical, prescription, dental, and vision coverage. The plan is tailored to meet the unique needs of seniors, providing them with access to a network of healthcare providers and special programs focused on maintaining health and independence. With Senior Care Options, members receive personalized care coordination, ensuring that their healthcare needs are met in a holistic and efficient manner.

Service area
The location where you live that allows you to be part of this health plan. Different areas have different health plans. For example, some plans are only offered in some counties of a state, while others are offered in the entire state.

Silver health plan
 One of 4 categories of Health Insurance Marketplace® plans (sometimes called “metal levels”). Silver plans fall about in the middle: You pay moderate monthly premiums and moderate costs when you need care. Important: If you qualify for “cost sharing reductions” (or “extra savings”) you can save a lot of money on deductibles, copayments, and coinsurance when you get care — but only if you pick a Silver plan. Silver plans are the most common choice of Marketplace shoppers.

SilverSneakers
A fitness program offered with some WellSense plans that is specifically designed for seniors, offering access to gym memberships, workout classes, and community activities focused on physical and social wellbeing. This program caters to varying fitness levels and includes options for both in-person and online classes, aiming to improve overall health and lifestyle through accessible and enjoyable fitness experiences.

Skilled nursing services
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Special Enrollment Period
A time outside the yearly Open Enrollment Period when you can sign up for health insurance if you have a qualifying life event. Examples of qualifying life events include you lose your current health coverage, move outside of your current plan’s service area or become eligible for both Medicare and Medicaid.

Specialist
A doctor who focuses on a specific area of medicine or a group of patients to diagnose, manage, treat, or prevent certain types of symptoms and conditions.

Specialty drug
A type of prescription drug that, in general, requires special handling or ongoing monitoring and assessment by a healthcare professional, or is relatively difficult to dispense. Generally, specialty drugs are the most expensive drugs on a formulary.

Step therapy program
A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

Subsidy
Financial assistance that helps pay for health insurance.

Summary of Benefits
An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you.

Telehealth
Refers to the use of electronic communication, like computers and smartphones, to access healthcare services remotely. This can include virtual doctor appointments, health education, and monitoring your health conditions without needing to physically visit a healthcare facility.

Treatment
The medical care given to a patient for an illness or injury. It can include a range of services such as medication, surgery, therapy, counseling, or lifestyle changes, aimed at managing or curing health problems.

UCR (usual, customary and reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent care
Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Waiting period
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.

Zero cost sharing plan
A plan available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is between 100% and 300% of the federal poverty level and qualify for premium tax credits.