Crohn’s & Colitis Glossary
High-Risk Pool Plan
Health insurance plans offered to individuals who have been locked out of the individual insurance market because of a pre-existing condition. Premiums for these plans can be up to twice as much as a healthy individual would pay for individual coverage.
Open Enrollment Period
The annual period when people can enroll in or make changes to their insurance coverage. Typically, open enrollment occurs yearly in from November–December but is important to know when your employer's period occurs. Outside of open enrollment, individuals may be eligible to enroll in a health insurance plan during a Special Enrollment Period if they have a qualifying life event (change in household, residence, or loss of healthcare coverage).
Out-of-Pocket Maximum
The most you pay before your health insurance plan begins to pay 100 percent of the cost for in-network services. This limit never includes your premium or care that your plan doesn't cover. Health insurance plans count all in-network copayments, deductibles, and coinsurance payments to this limit.
Peer-to-Peer Review
A scheduled phone conversation during which an ordering physician discusses the need for a procedure or drug with a physician represnting the health insurance company to obtain a prior authorization approval or appeal a previously denied prior authorization.
Pre-Existing Condition
A health problem, like Crohn's disease or ulcerative colitis, a person has before the date their health insurance starts.
Premium
The amount you pay every month for health insurance.
Prescription Drug Coverage
Health insurance that helps pay for prescription drugs.
Prior Authorization
A term that health insurance plans use which require a provider, clinic, hospital, case manager, or patient to apply for and receive approval for certain health care services. This can also be call pre-authorization, pre-approval, or prior approval.
Step Therapy
A protocol used by health insurance plans that requires patients to try and fail on one or more lower cost medications before they will provide coverage for the medication originally prescribed by the patient’s provider.
