Accreditation — a rigorous and comprehensive evaluation process where independent organizations assess the quality of the key systems and processes that manage care organizations use. Accreditation may also include an assessment of the care and service plans are delivering in important areas of public concern such as immunization rates, mammography rates, and member satisfaction. We recognize the following three accreditation organizations in our FEHB Guide.

NCQA — The National Committee for Quality Assurance.

Excellent — NCQA's highest accreditation status. Levels of service and clinical quality that meet or exceed NCQA's requirements for consumer protection and quality improvement AND achieve HEDIS results that are in the highest range of national or regional performance. Valid for 3 years.

Commendable — Meets or exceeds NCQA's requirements for consumer protection and quality improvement. Valid for 3 years.

Accredited — Meets most of NCQA's requirements for consumer protection and quality improvement. Valid for 3 years.

Provisional — Meets some but not all of NCQA's requirements for consumer protection and quality improvement. Valid for 3 years.

New health plan Accreditation — NCQA accreditation status - New health plans that have the structures and processes to monitor and improve patient care. Designed for plans less than 2 years old.

JCAHO — The Joint Commission on Accreditation of Healthcare Organizations.

Accreditation with Commendation — JCAHO's highest accreditation level, awarded to a plan that has demonstrated exemplary performance. This category will be discontinued in 2003. Valid for 3 years.

Accreditation without Recommendations - Demonstrates satisfactory compliance with JCAHO standards in all performance areas. Valid 3 years.

Accreditation with Recommendations — JCAHO accreditation status - Demonstrates satisfactory compliance with JCAHO standards in most performance areas. Valid for 3 years.

Provisional - Demonstrates satisfactory compliance with a subset of standards. Valid for 6 months until the plan is re-surveyed.

Conditional - Demonstrates the capability of achieving satisfactory compliance but has not done so.

URAC - American Accreditation Healthcare Commission/URAC

Accredited — Demonstrates full compliance with standards. Valid for 2 years..

Brochure — A plan's description of benefits, limitations, exclusions, and definitions under the FEHB Program.

Calendar year deductible — A fixed dollar amount you must pay out of pocket before the plan will begin reimbursing you. Separate limits are usually applied on a per person and per family basis.

Catastrophic limit — The maximum amount of certain covered charges you have to pay out of your pocket during the year. Setting a maximum amount protects you. Separate limits are usually applied on a per person and per family basis.

Coinsurance — The amount that you pay for each medical service you get, like a doctor visit. Coinsurance is a percentage of the cost of the service; a copayment is usually a fixed dollar amount you pay for a service.

Copayment — The amount that you pay for each medical service you get, like a doctor visit. Copayment is usually a fixed dollar amount you pay for a service; a coinsurance is a percentage of the cost of the service.

Covered charges — Services or benefits for which the health plan makes either partial or full payment.

Deductible — The amount you must pay for health care, before your health plan begins to pay. There is a deductible for each benefit period - usually a year. There may be separate deductibles for different types of services. Deductibles can change every year.

Fee-for-Service (FFS) Plan — Health coverage in which doctors and other providers receive a fee for each service such as an office visit, test, procedure, or other health care service. The plan will either pay the medical provider directly or reimburse you for covered services after you have paid the bill and filed an insurance claim. When you need medical attention, you visit the doctor or hospital of your choice.

Formulary — a list of both Generic and Brand Name drugs that are preferred by your health plan.

Gatekeeper — In a managed care plan, this is another name for the primary care doctor who gives you basic medical services and who coordinates proper medical care and referrals.

Health maintenance organization (HMO) — A health plan that provides care through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Your eligibility to enroll in an HMO is determined by where you live or, in some plans, where you work.

HEDIS* - Health Plan Employer Data and Information Set. A set of health plan performance measures (e.g., preventative medicine, prenatal care, acute and chronic disease and member satisfaction with health plans and doctors) that look at a plan's quality of care and services. NCQA requires HEDIS and JCAHO accepts HEDIS in accrediting health plans.

*HEDIS is a registered trademark of the National Committee for Quality Assurance

In network — The doctors, clinics, health centers, hospitals, medical group practices, and other providers that a plan contracts with or employs to care for its members. Examples include a Fee-for-Service plan's PPO or a Health Maintenance Organization. Members have less out-of-pocket costs when they use in-network providers.

Open Season Guide - a tool to help you understand the choices you have under the FEHB Program. The guide directs you through the abundance of plan choices and helps you make a decision.

Out of network — Members seek treatment from doctors, hospitals, and others outside the plan's panel of contracted or employed providers, and pay more to do so. Members in a PPO-only option who receive services outside the PPO network pay all charges.

Outpatient deductible — A fixed dollar amount you pay out-of-pocket for non-inpatient services. This is usually targeted at specific services or supplies and is different from a calendar year deductible.

Point of Service (POS) — A product offered by an HMO or FFS plan that has features of both. In an HMO, the POS product lets you use providers who are not part of the HMO network. However, there is a greater cost associated with choosing these non-network providers. You usually pay deductibles and coinsurances that are substantially higher than the payments when you use a plan provider. You will also need to file a claim for reimbursement, like in an FFS plan. The HMO plan wants you to use its network of providers, but recognizes that sometimes enrollees want to choose their own provider.

In an FFS plan, the plan's regular benefits include deductibles and coinsurance. But in some locations, the plan has set up a POS network of providers similar to what you would find in an HMO. The plan encourages you to use these providers, usually by waiving the deductibles and applying a copayment that is smaller than the normal coinsurance. Generally, there is no paperwork when you use a network provider.

Pre-tax Payment of Premium Contributions — The FEHB Program has incorporated the pre-tax payment of health insurance premium contributions as a tax-saving benefit feature for federal and postal employees. Career federal and postal employees have health benefits premium contributions automatically withheld from pay as "pre-tax money", which means the premium amount is not subject to income, Social Security, or Medicare taxes. Employees may choose not to participate in premium conversion by completing a form waiving this treatment and paying with "after-tax money". When your premium contributions are withheld on a pre-tax basis, certain Internal Revenue Service (IRS) guidelines affect your ability to change coverage. You may elect to reduce your coverage (cancel your FEHB enrollment or go from Self and Family to Self Only coverage) only during an FEHB Open Season, or upon have a Qualified Life Status Change.

Preferred Provider Organization (PPO) — Under the FEHB Program, PPOs are only available through enrollment in a Fee-for-Service (FFS) plan. The PPO is similar to FFS insurance except it uses a network of providers. PPOs give you the choice of using any doctor or other provider you want, or using one who is part of the plan's network. You don't have to use the PPO, but there are advantages if you do. (See Fee-for-Service.) However, if a FFS plan offers an enrollment option that is PPO-only, you must use network providers to get benefits.

Prescription Drugs, Brand Name and Generic — A brand name drug is approved by the Food and Drug Administration (FDA), and is supplied by one company (the pharmaceutical manufacturer). The drug is protected by a patent and is marketed under the manufacturer's brand name.

When a drug patent expires, other companies may produce a generic version of the brand name drug. A generic medication, also approved by the FDA, is basically a copy of the brand name drug and is marketed under its chemical name. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (i.e., pill, liquid, or injection).

Provider — A doctor, hospital, health care practioner, or health care facility.

Quality — Quality is how well health plans keep their members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person - and getting the best possible results.