Glossary

A

alternative care

Alternative care typically means services provided by chiropractors, naturopaths, acupuncturists and massage therapists. Naturopaths and acupuncturists may not be covered under your specific plan. Please contact Member Services.

allowable charge

The maximum amount a health care plan will reimburse a doctor or hospital for a given service.

annual deductible

The amount you are required to pay annually before reimbursement by your health care benefits plan begins.

annual out-of-pocket maximum

The maximum amount, per year, you are required to pay out of your own pocket for covered health care services after the deductible is met.


B

BlueCard® PPO

A national program that enables members to obtain health care services when traveling or living outside their Blue Plan service area. Members will have the same benefits when they travel or live away from home for an extended period of time. Learn more about the BlueCard PPO program.

BlueCard® Worldwide

Similar to the BlueCard program, the BlueCard Worldwide program gives members access to doctors and hospitals outside the United States. The BlueCard Worldwide network includes more than 200 countries and territories around the world.

Blue Access for MembersSM (BAM)

A secure member website available to Blue Cross and Blue Shield members. This website gives you immediate access to health care benefit information and easy-to-use tools. Take a tour of the site now.

Blue Care Connection®

A suite of benefit programs that provides members with personalized attention, support, online resources and health advocacy, helping you find the right resources, optimize your health care benefits and manage your medical conditions.

Blue Distinction®

A designation awarded by the Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality health care. Learn more about the Blue Distinction designation and facilities.

Blue Distinction® Centers

Blue Distinction Centers for Specialty Care are facilities that have been awarded the Blue Distinction designation and provide distinguished clinical care and processes in certain areas. Learn more about the Blue Distinction designation and facilities.

board certification

Board certification demonstrates a physician's exceptional expertise in a particular specialty and/or subspecialty of medical practice. Learn more about board certification  .


C

claim form

A form you or your doctor fill out and submit to your health care benefits plan for payment. View the forms available to you.

claim

An itemized bill for services that have been provided to you or a dependent under your plan such as your spouse or children.

COBRA

The Consolidated Omnibus Budget Reconciliation Act of 1985, better known as COBRA, requires group health care plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event which causes the loss of group health coverage. Qualifying events include reduced work hours, termination of employment, a child becoming an over-aged dependent, Medicare eligibility, death or divorce of a covered employee. Generally, COBRA participants pay the entire premium themselves.

coinsurance

A percentage of a covered service that you are responsible for paying or the percentage paid by your plan.

coinsurance maximum

The portion of billed services you would have to pay in a plan year for your portion of the covered expense. After that, Blue Cross and Blue Shield pays 100% of all covered expenses.

contracting hospital

A hospital that has contracted with a particular health care plan to provide hospital services to members of that plan.

coordination of benefits

In some cases, a person may have more than one kind of insurance coverage. For example, a person may have one plan from their employer and one from their spouse's employer. In this case, the two health plans work together to coordinate which one pays first, and how much. This process is called coordination of benefits.

copayment (or copay)

A fixed dollar amount the member pays the provider when they receive a medical service.

covered person

The eligible person enrolled in the group health care benefits plan and any enrolled eligible family members.

covered service

A service which is covered according to the terms in your health care benefits plan.


D

deductible

A fixed amount you are required to pay for medical services before health care benefits begin.

dependent

An eligible person, other than the member (generally a spouse or child), who has health care benefits under the member's policy.

drug formulary (or formulary)

A list of preferred prescription drugs covered by a health plan. The drugs listed on the formulary are chosen by a panel of doctors and pharmacists. Both brand and generic medications are included on the formulary.


E

effective date of coverage (or effective date)

The date your coverage begins or takes effect. Please note: The effective date can also represent the date a change in your coverage took effect. If you have questions, please call the number on the back of your ID card for more information.

emergency medical care

Services provided for the initial outpatient treatment of an acute medical condition, usually in a hospital setting. Most health care plans have specific guidelines to define emergency medical care.

Explanation of Benefits (EOB)

A document created after a claim payment has been processed by your health care plan. This document explains the actions taken on a claim such as the amount that will be paid, the benefit available, reasons for denying payment and the claims appeal process. EOBs are available both as a paper copy and online through your Blue Access® for Members account.

exclusions

Specific medical conditions or circumstances that are not covered under a health care plan.


F

family coverage

Health care coverage for a member and their eligible dependents.

formulary

See drug formulary.


G

generic drug

A prescription drug that is the generic equivalent of a brand name drug listed on your health plan's formulary. . The generic drug has the same active ingredients and strength as brand-name medications. Generic drugs typically cost less than the brand name drug and may save you money.

generic substitiute

A prescription drug which is the generic equivalent of a drug listed on your health plan’s formulary.

group health plan (or group)

A group of people covered under the same health care plan and identified by their relation to the same employer or organization (such as a union).


H

health exchange

A government-regulated market for buying health insurance coverage for individuals and families.

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that outlines the rules and requirements employer-sponsored group insurance plans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups.


I

indemnity plans

Historically, this term has been used to apply to plans that pay benefits as a flat dollar amount (for example: $100 per day for a hospital room). More recently, it has come to be used for any traditional (non-PPO, non-HMO) medical plan.

in-network

Services provided or coordinated by a contracted physician or at a contracted hospital and paid at a higher benefit level.

inpatient services

Services provided when a member is registered as a bed patient and is treated as such in a health care facility such as a hospital.


J


K


L


M

Medicare

The largest national health insurance program, covering health care services such as hospital stays, skilled nursing and physician services for those over the age of 65 and other eligible individuals.

The largest national health insurance program, covering health care services such as hospital stays, skilled nursing and physician services for those over the age of 65 and other eligible individuals.

Medicare Advantage (or Medicare Part C)

A type of Medicare plan that offers hospital and medical coverage through a network of providers, like an HMO or PPO. Often called Part C, it replaces Medicare Parts A and B.

These plans are offered through private insurance companies approved by Medicare.

Medigap

A type of health plan, offered by private insurance companies, that is intended to pay some of the health care costs ("gaps") that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles.

medical group

A licensed health care facility, program, agency, doctor or health professional that contracts with a health plan to deliver health care services to plan members.

member

The person to whom health care coverage has been extended by the policyholder (generally their employer) or any of their covered family members. Sometimes referred to as the insured or insured person.


N

network

See provider network.

no referrals

No referrals means a member can go directly to a specialist without first seeing their regular doctor.

non-network providers

A hospital or physician that has not contracted with a particular health care plan to provide hospital services to members in that plan. Some health plans cover non-network providers, but your costs will almost always be higher.


O

 

office visit

A formal, face-to-face meeting between you and a health professional in a clinic, office or hospital outpatient area. Same as an 'office call.'

out-of-network

Services provided by doctors and hospitals who have not contracted with your health plan.

out-of-pocket expense

Money you spend when using health care services. Your deductible and coinsurance are kinds of out-of-pocket expense. Your premium is not usually considered an out-of-pocket expense.

out-of-pocket maximim

A predetermined amount of money that an individual must pay before insurance will pay 100% for an individual's health-care expenses.

outpatient

Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.


P

Participating Provider Option (PPO)

A health care plan that supplies services at a higher level of benefits when members use contracted health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network, however the plan member generally shares a greater portion of the cost for such services.

pre-admission or pre-notification

The process by which you or your doctor notifies Blue Cross and Blue Shield, before you undergo a course of care such as a hospital admission or a complex diagnostic test.

preferred provider network

A group of providers (such as hospitals and physicians) who agree to charge a pre-negotiated rate for everyone on a particular health plan.

preferred provider organization (PPO)

A health care plan that provides services at a higher level of benefits when members use contracted health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network, however the plan member generally shares a greater portion of the cost for such services.

premium

The amount an individual pays for coverage. Same as rate.

prescription drugs

Prescription drugs must be ordered by a doctor and obtained at a retail or mail order pharmacy.

prescription drug list

See drug formulary.

preventive care

Routine services like well-child care, immunizations, adult physicals and exams, sometimes lab and x-ray services that help prevent health issues or detect them early on. Preventive care services vary from plan to plan.

provider

A licensed health care facility, program, agency, doctor or health professional that provides health care services.

provider network

A group of providers (such as hospitals and physicians) who agree to a pre-negotiated price for services they provide. To get that price, a patient must be covered by a particular health plan that uses that network. On some health plans, a patient has less or no insurance coverage if they see a provider who is not in their network.


Q

qualifying event

An event that happens to make a person eligible for continued insurance coverage under COBRA or state law. Examples of qualifying events: termination of employment, death or divorce.


R

rate

See premium.


S

second opinion

An evaluation of a health care issue made by another doctor after a diagnosis has been made, usually when surgery is being considered. A patient may get an opinion from one provider about the best treatment, and then ask other providers for their recommendations or "second opinions." Some health plans require second opinions; others encourage them.

service area

The geographic area where an insurance company sells and delivers services. A service area can also be product-specific.

skilled nursing facility (SNF)

A facility licensed to provide inpatient care, including round-the-clock nursing.

Special Beginnings® Program

A maternity program available to Blue Cross and Blue Shield members. Learn more about the Special Beginnings program.

stop-loss

See out-of-pocket maximum


T


U

underwriting

The process of identifying and classifying the potential risk of insuring a person or group of people.

up-front benefit

A benefit that does not apply towards the deductible. For example, an annual physical could be covered at 100% without first having to meet a deductible.


V


W


X


Y


Z