Glossary of Terms
These terms are for illustrative purposes only. Please refer to your certificate of Health Care Benefits for the definitions applicable to your health care coverage.
Coinsurance - a percentage of an eligible expense that you are required to pay for a covered service.
Deductible - the amount you must pay before the Plan begins to pay benefits.
Explanation of Benefits (EOB) - after you or your provider submit a claim, Blue Cross and Blue Shield will send you an explanation that will give you claims payment information, including the amount paid to the provider and any amount you may owe. If a deductible and/or coinsurance applies, the amount applied to your deductible and out-of-pocket maximum will also be shown.
Network - The providers and facilities contracted with to render health care to members. Members receiving in-network care generally obtain a higher level of benefits.
Out-of-Pocket Expense - the annual maximum limit you may pay for covered expenses. After your share of eligible expenses (deductible and coinsurance) reaches a certain limit, the Plan will pay 100 percent (unless balance billing applies) of most covered medical expenses for a covered plan member for the remainder of the calendar year.
Out-of-pocket maximum - the most you pay in coinsurance during a benefit plan year. After you reach your out-of-pocket maximum, your medical plan option pays 100% of eligible expenses for the remainder of the benefit plan year.
Primary care physician (PCP) - a family practitioner, general practitioner, internist or pediatrician who provides care and coordinates your medical treatment. Network PCPs meet qualification standards and are subject to periodic review.
Maximum Allowable Charge (MAC) - The maximum charge for services rendered or supplies furnished by a health provider that qualifies as covered expenses that Blue Cross and Blue Shield will pay in whole or part, subject to copayments, deductibles and coinsurance amounts. The MAC applies to out-of-network services only.
In-network Provider - A physician, hospital or other health care provider that joins a managed care plan and provides services based on negotiated fees. Generally, using an in-network provider will save you money in the form of copayments, lower deductibles and a higher reimbursement level, and the provider will file claims for you.
Out-of-network Provider - An out-of-network provider does not participate in the Blue Cross and Blue Shield plan and therefore charges a non-discounted fee. Payments for out-of-network services are based on your benefit plan and maximum allowable charges (MAC). Also your portion of the coinsurance and your deductible will be higher when you go out of network for services. When you visit an out-of-network provider, in most cases, you may need to file a claim for reimbursement. Many providers who are not members of the network will file claims for you, but not all out-of-network providers perform this service. If you use an out-of-network provider, be sure to talk with the provider's staff about whether you or the provider will file your claim.
Formulary - A listing of preferred drugs selected by a panel of physicians and pharmacists. A drug on the formulary benefits Blue Cross and Blue Shield members as it gives you access to quality medications at a lower co-payment or coinsurance. Both brand and generic drugs that provide effective, safe and appropriate drug therapies are listed on the Formulary. You may use a drug not listed on the Formulary; however, a higher copayment or coinsurance may apply.
Participating IPA - Any duly organized Individual Practice Association of Physicians which has a contract or agreement with a Blue Cross and Blue Shield plan to provide professional and ancillary services to persons enrolled under a benefit program.
Participating Medical Group - Any duly organized group of Physicians which has a contract or agreement with Blue Cross and Blue Shield plan to provide professional and ancillary services to persons enrolled under a benefit program.
Woman's Principal Health Care Provider - A physician licensed to practice medicine in all of its branches, specializing in obstetrics or gynecology.