Glossary

Common Terms and Definitions

Affordable Care Act
A comprehensive law passed in 2010, aimed at reforming America's health care system to improve access and affordability for more Americans

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 benefit plan begins
The deductible requirement does not apply to preventive services

Annual Limit
An annual dollar limit your plan may pay during one year for a certain treatment or service

Claim
An itemized bill for services provided to a member

Claim Form
A form you or your doctor fill out and submit to your plan for payment

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

Contracting Hospital
A hospital that has contracted with a Blue Cross and Blue Shield PPO plan to provide hospital services to members of that plan at a discounted rate

Copayment
A fixed dollar amount you are required to pay for covered services at the time you receive care

Covered Person
The eligible person enrolled in the health care benefits plan and any enrolled eligible family members

Covered Service
A service that is covered according to the terms in your health care benefit plan.

Deductible
A fixed amount of the eligible expenses you are required to pay before reimbursement by your health care benefit plan begins

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

Effective Date of Coverage
The date your coverage begins. Please note: The effective date can also represent the date a change in your coverage takes effect. If you have questions, call the number on the back of your ID card

Exclusions
Specific medical conditions or circumstances that are not covered under your plan

Explanation of Benefits (EOB)
An EOB is created after a claim payment has been processed by your health care plan. It 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

Family Coverage
Health care coverage for a primary policyholder (called a "subscriber") and his or her spouse and any eligible dependents

HIPAA
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

In-Network
Services provided by a physician or other health care provider that has contracted with a Blue Cross and Blue Shield PPO plan 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

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.

Network
The group of doctors, hospitals and other health care professionals that Blue Cross and Blue Shield has contracted with to deliver medical services to its members

Non-Contracting Hospital
A hospital that has not contracted with BCBS to provide hospital services to members in that plan

Out-of-Network
Services provided by doctors and hospitals who have not contracted with a Blue Cross and Blue Shield PPO

Out-of-Pocket Maximum
The maximum amount you have to pay for expenses covered under your health care plan, after any deductible is met, during a defined benefit period

Outpatient Services
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

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

Provider
A licensed health care facility, program, agency, doctor or health professional that delivers health care services

Specialist
A health care professional whose practice is limited to a certain branch of medicine, including specific procedures, age categories of patients, specific body systems or certain types of diseases.