Glossary

 
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Same-Day Surgery

Same-day, ambulatory or outpatient surgery is surgery that does not require overnight stay in a hospital.

Schedule of Allowances

The Schedule of Allowances is a EmblemHealth listing of the payments for covered medical or dental services rendered by EmblemHealth's Participating Providers. The Schedule of Allowances applicable to your Certificate is on file with the New York State Insurance Department. It is available for inspection at the offices of the New York State Insurance Department and at EmblemHealth's offices. Payment is made under the Schedule of Allowances directly to your Participating Provider.

Second Opinion

The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed. Refer to your contract for specific guidelines.

Self Insurance

Practice of an individual, group of individuals, employer or organization assuming complete responsibility for the losses that might be insured against such as healthcare expenses. Often, self-insured groups maintain a fund out of which is paid the contingent liability subject to self-insurance.

Service Area

The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

Short-term Care

Refers to treatment or care intended to improve or restore a member's functioning within a reasonable period of time. Short-term care is expected to produce a positive result, not maintain functioning or prevent decline.

Skilled Nursing Facility (SNF)

A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.

Small Business Health Care Tax Credit

The Affordable Care Act gives a tax credit for qualifying small employers who pay at least 50% of their employees’ health premium costs. Qualifying for-profit small employers may be eligible for a tax credit of up to 35% of the cost of health premiums paid by the employer. The greatest tax credit for qualifying tax-exempt small employers is 25%.

Specialized Services

Services provided by specialists, not by your PCP. For example, an allergist (who treats allergies) or a radiologist (who uses x-rays for diagnosis and treatment) are specialists.

Specialty Care Center

A facility accredited or designated by an agency or the state or by a voluntary national health organization as having special expertise in treating a specified condition or disease.

Specialty Care Coordinator

The specialty care coordinator is a network specialist with expertise in a disabling, degenerative, or life-threatening condition, who manages the treatment of a member with such a condition and shares authority for treatment options with the PCP. In some cases, the specialty care coordinator will initiate an Out-of-Network referral.

Speech Therapy

Treatment of the correction of a speech impairment which resulted from birth, disease, injury, or prior medical treatment

Subscriber

A subscriber is an active member enrolled under a EmblemHealth group Certificate or an individual enrolled under a direct payment contract. A "Retiree" may also be a subscriber under a group Certificate. Please review the terms of your Certificate to determine whether Retirees are eligible for coverage. You may also contact EmblemHealth or your group health plan administrator for additional information.

Subsidy
A form of financial assistance the US government provides to help people pay the out-of-pocket costs of a health plan (copays, coinsurance and deductibles). To qualify for this help, a person must have an income between 100% and 250% of the Federal Poverty Level and enroll in a Silver Plan through the New York Health Benefit Exchange.
Substance Abuse/Chemical Dependency

The use of one or more drugs for purposes other than those for which they are prescribed or recommended.