Old man and boy fishing together on river for fun.


A group of health care providers who give coordinated care, chronic disease management and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost savings. At BCBSNE, our value-based ACOs are key to providing our members with total care
An agreement between a health insurer and an employer/organization to administer health plan benefits on the employer's behalf. This means the employer pays the claims, but the health insurance company does all the administrative work.
A tax credit that can be used to lower your monthly premium on plans purchased through the Health Insurance Marketplace®.
A person or business who can help you determine your health care coverage needs and apply for coverage. They're also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer's plans. Some brokers may only be able to sell plans from specific health insurers.
If you have an aggregate deductible and/or out-of-pocket maximum, your entire family deductible must be met before the health insurance plan begins to pay for services.
An amount we use to calculate our payment of covered services. This amount will be based on the contracted amount for in-network providers or the out-of-network allowance and is the maximum amount that an in-network provider can charge for a covered service.
AEP is for individuals on Medicare who have not yet joined a plan, or are already enrolled in a plan and want to switch, with coverage starting Jan. 1. The AEP applies to Medicare Advantage or Medicare prescription drug coverage only.
The additional amount you may be billed by an out-of-network provider when their billed charge exceeds the allowable charge paid by us (sometimes considered a ‘surprise bill’).
A distinction awarded to providers for helping their patients get high-quality care in the right place, at the right time as well as for keeping costs down and achieving better health outcomes.
The BlueCard Program links contracting health care providers and Blue Cross and Blue Shield Plans across the country through a single electronic network for claims processing and reimbursement. Blue Cross and Blue Shield of Nebraska members and their covered dependents receive in-network benefits even when they’re out of state by using hospitals, doctors and other health care providers who are part of the local Blue Cross and Blue Shield Plan’s BlueCard PPO network. Not all plans include BlueCard; check your plan documents or call the member services number on the back of your member ID card to determine if your plan includes BlueCard.
A drug sold by a drug company under a specific name or trademark protected by a patent. Brand-name drugs may be available by prescription or over the counter.
One of four plan categories (also known as "metal levels") in the Health Insurance Marketplace®. Bronze plans usually have the lowest monthly premiums but the highest costs when you get care.
The primary plan document for fully insured groups outlining the member's benefits and responsibilities under the health insurance policy.
Consolidated Omnibus Budget Reconciliation Act.” COBRA provides for an extension of group coverage for employees and their covered family members after a “qualifying event,” such as termination of employment, divorce and death. Not all employers are subject to COBRA, but generally, those with 20 or more employees are.
The percentage of the bill you pay for covered services after your deductible has been met.

Coordination of benefits is used when a member has two health insurance plans. This process allows the two plans to work together, getting you the most out of your coverage. One plan becomes your primary plan, paying your claims first. The second plan becomes your secondary plan, which may pay toward the remaining cost, depending on the plan. Understanding which plan is your primary and which plan is your secondary is important to help prevent delays in claims processing.

Members may complete this form online on myNebraskaBlue.com or by downloading the Coordination of Benefits Form.
A fixed amount you pay when you get a covered health service. For example, a doctor's office visit.
The share of costs covered by your health insurance plan that you pay out of pocket. This term generally includes deductibles, coinsurance, copays or similar charges, but it doesn't include premiums, balance billing amounts for out-of-network providers or the cost of noncovered services.
A discount that lowers the amount you have to pay for deductibles, copays and coinsurance. In the Health Insurance Marketplace®, cost-sharing reductions are often called "extra savings." If you qualify, you must enroll in a plan in the Silver category to get the extra savings.
When you fill out a Marketplace application, you'll find out if you qualify for premium tax credits and extra savings. You can use a premium tax credit for a plan in any metal category. But if you are eligible for extra savings, too, you'll get those savings only if you pick a Silver plan.
If you qualify for cost-sharing reductions, you also have a lower out-of-pocket maximum — the total amount you'd have to pay for covered medical services per year. When you reach your out-of-pocket maximum, your insurance plan covers 100% of all covered services.

If you're a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.
The fixed dollar amount you pay for covered health services each plan/policy year before your insurance begins to pay.
Regulatory organization for the insurance industry within the state.
Insurance coverage for family members of the subscriber/policyholder, such as spouses, children or partners.
A direct primary care plan is a health care plan between you and a health care provider. You do not pay a monthly premium to an insurance company; instead, you pay a monthly fee to the health care provider. These direct primary care providers do not accept any form of insurance, and your monthly fee only covers visits to the direct care provider. Any visits to specialists, hospitals or other health care providers would not be covered under a direct primary care plan.
If you have an embedded deductible and out-of-pocket maximum your family members may combine their covered expenses to satisfy the required family deductible or out-of-pocket maximum; however, no one family member contributes more than their individual deductible or out-of-pocket maximum amount to satisfy the family deductible or out-of-pocket maximum.
Any covered services received in a hospital emergency room setting.
This is a type of plan and provider network with rates and provisions negotiated by a self-funded employer group, usually with help from an insurance company and broker, specifically for that group's members.
A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors' services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services and more. Some plans cover more services.
Another term for the Health Insurance Marketplace®, a service available in every state that helps individuals, families and small businesses shop for and enroll in affordable health insurance. The Marketplace is accessible through websites, call centers and in-person assistance.
Services that your health insurance plan doesn't cover.
A plan where services are covered only if you use doctors, hospitals and other health care providers in the plan’s network (except in an emergency or as otherwise required by law). Outside of an emergency, there are no benefits for services received from out-of-network providers. 
A document provided to members after they receive care that shows the covered amount of their services and what they owe the health care provider.
An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copays and deductibles, qualified prescription drugs, insulin and medical devices.
A traditional type of health insurance option sponsored by an employer/organization. The employer pays monthly premiums to the insurance company; this is a fixed dollar amount that can change annually depending on claims utilization.
A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs as safe and effective as brand-name drugs.
One of four health plan categories (or "metal levels") in the Health Insurance Marketplace®. Gold plans usually have higher monthly premiums but lower costs when you get care.
A short period after your monthly health insurance payment is due. If you haven't made your payment, you may do so during the grace period and avoid losing your health coverage.
A health plan offered by an employer or employee organization that typically provides health coverage to employees and their families.
A requirement that health plans must permit you to enroll regardless of health status, age, gender or other factors that might predict the use of health services.
A service, operated by the U.S. federal government, that helps people shop for and enroll in health insurance.
A plan that limits coverage to care from doctors who work for or contract with the HMO. Out-of-network care is typically only covered in the case of an emergency. You may be required to live or work in the HMO service area to be eligible for coverage.
Health Reimbursement Arrangements (HRA) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the arrangement. Health Reimbursement Arrangements are sometimes called Health Reimbursement Accounts.
A tax-advantaged savings account that can be funded by individuals whose only health care coverage is a high-deductible health plan (HDHP). An HSA is an alternative way to pay for qualified health care expenses and save for future qualified health care expenses on a tax-free basis. Expenses such as out-of-pocket costs for office visits, prescription drugs, dental expenses and laboratory tests may be paid from an HSA.
A program of care provided for persons diagnosed as terminally ill, and their families.
A provider contracted by your insurance company to accept an agreed-upon payment for covered services.
Care you receive that requires admission to a hospital.
A plan that offers discounts on medical services. These discounts vary depending on the provider and treatment, and there is no cap on out-of-pocket costs. These are not full health insurance policies.
The process used by insurance companies to review your demographic information and medical history to determine eligibility for coverage and premium amount.
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Services that are not payable under your health insurance contract.
The window of time you can purchase or renew your health insurance.
A term for providers that aren’t contracting with your insurance plan. Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.
Your expenses for medical care that aren’t reimbursed by your plan, including deductibles, coinsurance and copays for covered services.
Care you receive at a hospital or health care facility without being admitted.
A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer.
A type of plan where you pay less if you use doctors, hospitals and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor to see a specialist.
A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. To find out when your policy year begins, you can check your policy documents or contact your insurer.
Any health condition for which you’ve had, received medical advice or treatment for, prior to the start of your health insurance coverage.
A Nebraska Preferred Center is a surgical facility that has demonstrated high quality through low readmission and infection rates, high patient satisfaction and lower costs for spine surgeries and total knee and hip replacements.
A plan where you pay less out of pocket if you use providers in your plan’s network. You can use doctors, hospitals and other health care providers outside the network without a referral, although you will have higher out-of-pocket costs.
The amount you're charged each month for your health insurance plan.
A list of drugs covered by your prescription drug plan. Coverage of these drugs is subject to your benefit plan's design, and the list is subject to change. 
Routine health care that includes screenings and check-ups to prevent illness, disease or other health problems.
A physician who has a majority of his or her practice in the fields of internal or general medicine, obstetrics/gynecology, general pediatrics or family practice.
A health plan that is health savings account (HSA)-eligible has a higher deductible than non-eligible plans. The premium is typically lower, but you will pay more upfront for medical costs (deductible) before your insurance plan starts to share in the costs (coinsurance). These plans can be combined with an HSA, allowing you to save and pay for certain medical expenses tax free.
A change in your life situation that makes you eligible for a special enrollment period (SEP) to enroll for coverage outside the standard open enrollment period (OEP). Qualifying life events include, but are not limited to, loss of health coverage, changes in family/household or changes in residence.
The retroactive cancellation of a health insurance policy based on the terms of your plan.
A brief overview of the member’s deductible and coinsurance responsibilities provided at the start of a plan year, and often including member ID cards.
The document that outlines the cost sharing associated with health care services covered by your plan. This is the most common documents for members to reference for their health care benefits.
Temporary health insurance plans that offer coverage from one to 36 months and typically do not cover preexisting conditions, maternity or mental health. These plans are great for healthy individuals looking to fill a coverage gap.
One of four categories of Health Insurance Marketplace® plans (sometimes called "metal levels"). Silver plans fall about in the middle: You pay moderate monthly premiums and moderate costs when you need care.
The time outside of the open enrollment period (OEP) when you can enroll or make changes to your health plan if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving, etc.).
A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.
The primary policyholder. This person is typically responsible for paying premiums or whose employment is the basis for eligibility in a health plan.
An unexpected ‘balance bill’ resulting from a service you received from an out-of-network provider you had thought to be in your network.
A consultation with a health care provider in a remote setting (as opposed to an in-office, in-person visit), facilitated by video chat or phone. Many in-network providers offer their own telehealth options.
BCBSNE's value-based care (VBC) program, delivered in collaboration with Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) in Nebraska and, via other BCBS plans, across the U.S. 

Total Care providers are reimbursed based on the quality of the care they coordinate, rather than the number of services performed - resulting in lower costs of care, better relationships and experiences between patients and providers, and better health outcomes.