Glossary

Affordable Care Act:

The Affordable Care Act (ACA) is a United States federal statute signed into law on March 23, 2010, and is designed to make health care more affordable, accessible and of a higher quality.

Allowable Charge:

An amount we use to calculate our payment of covered services. This amount will be based on either the Contracted Amount for In-network Providers or the Out-of-network Allowance.

Annual Election Period:

When you can sign up for, change, or disenroll from a Medicare Advantage, Part D plan or Medicare. The AEP runs from October 15 to December 7 each year.

Blue Distinction Total Care:

Arrangement with provider for patient and payment value.

BlueHealth Advantage:

BlueHealth Advantage is the umbrella name for our company Wellness Programs. BlueHealth Advantage is utilized both internally for our employees as well as an external program for our groups. Visit our BHA SharePoint page to find out what is happening in our internal wellness program! Visit the external BlueHealth Advantage website for great wellness resources that are accessible for everyone.

Catastophic Plan:

An affordable way to protect yourself. Only adults under 30 and individuals exempted from the individual mandate because they cannot find affordable insurance are allowed to purchase catastrophic plans.

Coinsurance:

The percentage of the bill you pay after your deductible has been met.

Coordination of Benefits:

Provision regulating payments to eliminate duplicate coverage when a claimant is covered by multiple group plans.

Copay:

A fixed amount you pay when you get a covered health service.

Deductible:

The amount you pay for health services each calendar year before your insurance begins to pay.

Department of Insurance:

Regulatory organization for the insurance industry within the state.

Emergency Care Services:

Any covered services received in a hospital emergency room setting.

Explanation of Benefits:

Document provided to customers that shows the covered amount of their services and what they owe.

Health Maintenance Organization:

A health benefit program that offers benefits to members when they obtain services from the network of physicians and hospitals designated to the Association as HMO providers and as consistent with applicable law. Benefits are eliminated when the member obtains care from a non-HMO provider except for emergency services and authorized referrals. Generally, HMO members select a primary care provider/group.

High Deductible Health Plan:

A health plan that satisfies certain requirements with respect to deductibles and out-of-pocket expenses. Specifically, for self-only coverage, an HDHP has an annual deductible of at least $1,000 and annual out-of-pocket expenses required to be paid (deductibles, co-payments and other amounts, but not premiums) not exceeding $5,000. For family coverage, and HDHP has an annual deductible of at least $2,000 and annual out-of-pocket expenses required to be paid not exceeding $10,000. In the case of family coverage, a plan is an HDHP only if, under the terms of the plan and without regard to which family member or members incur expenses, no amounts are payable from the HDHP until the family has incurred annual covered medical expenses in excess of the minimum annual deductible. Amounts are indexed for inflation and 2005 amounts are shown. A plan does not fail to qualify as an HDHP merely because it does not have a deductible (or has a small deductible) for preventative care (e.g., first dollar coverage for preventative care). However, except for preventative care, a plan may not provide benefits for any year until the deductible for that year is met.

Hospice:

A program of care provided for persons diagnosed as terminally ill, and their families.

Inpatient care:

Care you receive that requires admission to a hospital.

In-Network Provider:

A provider contracted by your insurance company to accept an agreed upon payment for covered services.

Medicare Advantage:

The Medicare Modernization Act (MMA) renamed the “Medicare+Choice” program “Medicare Advantage” and created the regional preferred provider organization (PPO) option in addition to the other available managed care plans – health maintenance organizations (HMOs), preferred provider organizations (PPOs), provider-sponsored organizations (PSOs), private fee-for service (PFFS) plans, and medical savings accounts (MSAs).

Medicare Prescription Drug Benefit:

Established by the Medicare Modernization Act (MMA) and provides Medicare beneficiaries front-end and catastrophic prescription drug coverage effective 2006.

Medicare Supplement:

A policy guaranteeing that a health plan will pay a subscriber's deductible, coinsurance and copayments and will provide additional health plan or non-Medicare coverage for services up to a predefined benefit limit. In essence, the product pays for the portion of the cost of services not covered by Medicare. Also called Medigap.

Mental Illness:

A pathological state of mind producing clinically significant psychological or physiological symptoms (distress) together with impairment in one or more major areas of functioning (disability) wherein improvement can reasonably be anticipated with therapy, and which is a condition listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV, or any subsequent version).

Noncovered Services:

Services that are not payable under the contract.

Open Enrollment Period:

The window of time from November 1, 2016 - January 31, 2017 when you can purchase health insurance.

Out-of-network:

A term for providers that aren’t contracting with your insurance company. (Tend to be more expensive than in-network providers.)

Out-of-network provider:

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

Out-of-pocket:

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance, and copayments for covered services, plus all costs for services that aren't covered.

Outpatient care:

Care you receive at a hospital without being admitted.

Participating Provider:

A licensed practitioner of the healing arts, or qualified provider of health care Services, who is a participating provider in the BlueCard Program.

Pediatric services:

Health care for kids, including dental care and vision care.

Penalty:

If you can afford health insurance but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

Physician:

Any person holding an unrestricted license and duly authorized to practice medicine and surgery and prescribe drugs.

Preferred Partner Organization:

A health benefit program that offers the highest level of benefits to members when they obtain services from any physician or hospital designated as a PPO provider. Substantial benefits still are provided when the member obtains care from another provider of choice. No primary care physician gatekeeper/referral is required for access to PPO providers. The PPO provider network includes, at a minimum, hospitals and physicians and may include, at a minimum, hospitals, physicians and other health care providers.

Premium:

The amount you pay to your health insurance company each month.

Preventive Services:

Routine health care that includes screenings, check-ups and patient counseling to prevent illness, disease, or other health problems.

Primary Care Physician:

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.

Rehab Services:

Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.

Skilled Nursing Care:

A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

Substance Abuse Disorder Services:

Includes behavioral health treatment, counseling, and psychotherapy.

Special Enrollment Period:

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

Specialist:

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.

Tiered Benefit Plan:

A health care plan featuring multiple levels of benefits based on the network status of a particular provider.

Urgent Care Facility:

A facility, other than a hospital, that provides covered health services that are required to prevent serious deterioration of your health, and that are required as a result of an unforeseen sickness, injury or the onset of acute or severe symptoms.

HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

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.