A
Allowable Charge
The amount your health plan pays of the charges from a doctor or hospital for service. The “allowable charge” is different that what the provider would normally charge for the service because BCBSMT has negotiated a discount for you as a member.
Annual Limit
The total amount a plan will pay for covered treatments and services in one year. For example, a plan may only pay for one set of dental X-rays a year.
B
Balance Billing
Sometimes, a doctor, hospital or other provider may bill you for the difference between what they normally charge and the amount covered by your health plan. A network provider does not balance bill because they have agreed to the BCBSMT discounted rate. If you visit a provider not in your plan’s network, the provider has the right to require you to pay the part of the bill your plan didn’t cover.
Benefits
Everything covered by your health plan is part of your plan’s benefits. Benefits can include doctor’s visits, prescriptions, tests, hospital stays, medical equipment and more.
C
Catastrophic Plan
You must be under the age of 30 or qualify for a “hardship” or “affordability” exemption to have a catastrophic plan. This type of health insurance plan has low monthly premiums, but much higher out-of-pocket limits, and may only cover preventive services and care considered essential, like emergency care and hospital stays.
Claim
After getting care from a provider, a bill (claim) is sent to BCBSMT for payment. The claim is usually filed directly by the provider, but some may require you to pay up front and file your own claim for reimbursement.
Claim Form
If you see a provider that doesn’t file insurance claims for their patients, you may have to pay them directly, then get reimbursed. To get reimbursed, you fill out a claim form and submit it to BCBSMT. We then pay you, rather than the provider. You can find the correct claim form in Form Finder.
COBRA
This federal law helps people keep health coverage for a temporary period – usually 18 months – when a “qualifying” event happens. The loss of employment is considered a qualifying event. So is the loss of coverage for dependents covered by an employee’s health plan.
Coinsurance
Coinsurance is your share of costs you pay for care. It may be a percentage of the cost, or a set amount. For example, if your coinsurance is 20% and your plan allows $100 for an office visit , you pay $20 for the visit if you’ve met your deductible. If you haven’t yet met your deductible, you may pay the full $100.
Contracting Hospital
A hospital that provides hospital services at a discounted rate for BCBSMT plan members.
Coordination of Benefits
If you are covered by two or more health plans, how do you know which plan covers what? The plans work together to figure out who pays the costs for a medical claim—and what amount they each pay. One insurer may pay the entire claim, or the cost may be shared. With COB, health plans make sure you get maximum coverage when you need care.
Copay
A set amount you pay every time you see a doctor or get a prescription filled. Your copay amounts can be found on your BCBSMT member ID card.
Cost Sharing Reduction
This discount lowers the amount you pay for deductibles, coinsurance and copays. You may get it if your income is below a certain level and you have a silver health plan. Members of federally recognized tribes may also qualify for this savings.
Covered Person
The person enrolled in the health plan, plus their eligible family members and dependents.
Covered Service
A health service or procedure that is covered and paid for by your health plan. Not every plan pays for every type of care. For example, a plan may cover routine OB/GYN exams, but not fertility treatments. It may cover regular dental checks, but not teeth whitening. If you receive a non-covered service, you will be responsible for paying for the service.
D
Deductible
Before your health plan starts to pay for medical care and prescription costs, you pay 100% of these costs until you reach a set dollar amount known as your deductible. This set amount could be $1,000 for an individual policy. It might be higher or lower depending on the plan you select and its options for a deductible and monthly premium. Once you pay your deductible in full, you then only cover your copay and coinsurance costs. The deductible resets at the start of each new year and when you enroll in a new plan.
Dependent
A person (often a spouse or child) who has health care benefits under your plan.
Drug List
A list of all the brand name and generic drugs covered by your health plan. The list is based on recommendations by doctors and pharmacists across the U.S. They’re chosen based on safety, cost and how well they work. You can check your plan’s drug list to see if a drug your doctor orders is covered and how much it will cost before you fill it. Just look on your Blue Access for MembersSM account or on MyPrime.com. If it isn’t covered, ask your doctor or pharmacist if there is an equivalent drug on the approved drug lists that may be substituted. The drug list changes from time to time, so check for updates on the BCBSMT website and in Blue Access for Members.
E
Effective Date
The date, month and year your health coverage starts.
Emergency Medical Care
Immediate care to treat an urgent medical condition (such as a broken bone), or one that might be life-threatening, such as a heart attack or stroke.
Employer Shared Responsibility Payment (ESRP)
Some employers with 50 or more full-time employees must offer health insurance to full-time employees and their dependents. If it doesn’t, the employer must make a tax payment called an ESRP.
Essential Health Benefits
There are 10 categories of health care services considered essential to your good health, so they are covered by every health plan. These essential benefits include doctors’ services, inpatient and outpatient hospital care, prescription drugs, pregnancy and childbirth, mental health services and dental care for children.
Exclusions
Your plan may not cover some services. For example, it may not pay for the cost of plastic surgery unless it is to repair injuries from an accident.
Explanation of Benefits (EOB)
Every time you get care, you get a follow-up statement from BCBSMT. It shows what costs are covered by your plan. It usually notes three things: the cost of the care you received; any money you saved by seeing an in-network provider; plus, any out-of-pocket amount you may have to pay the provider.
Family Coverage
This is a health insurance policy that covers an entire family. Employers often offer it as a benefit so their employees can include their spouse, eligible children and other eligible dependents. It can include health insurance, dental insurance, life insurance, accidental death and more. If you don’t get health insurance through an employer, you can enroll in an individual and family plan directly with BCBSMT or through a state or federal Health Insurance Marketplace.
F
Flexible Spending Accounts (FSA)
A special savings account set up to pay for out-of-pocket health care expenses with money in the account. Dollars that you deposit into the account are tax-free and can help you save money on your yearly income taxes. Insurance copays, deductibles, prescription drugs, insulin and medical devices are all things that can be paid for with FSA funds.
G
Generic Drug
A prescription drug that isn’t a name-brand drug. It is a no-name version that has the same ingredients and usually works just as well as the name brand, but costs a lot less.
Grandfathered Health Plan
When the Affordable Care Act went into effect in 2010, it helped make health care more affordable and available to more people through the Health Insurance Marketplace. But if you were in a plan before 2010, you could keep your plan that may not have all the benefits of ACA plans.
Group Plan
A health plan that provides health care coverage to its members or employees and their families. BCBSMT offers group plans to companies, small businesses, associations, organizations, churches, unions and municipalities.
Guaranteed Issue
This simply means that if you want insurance, you can get it. You can’t be denied coverage based on health status, age, gender or other factors that might predict how much you will use health care services.
H
Health Coverage or Health Plan
A group health plan offered through work, an individual or family plan you buy directly from BCBSMT or the Health Insurance Marketplace, or government plans through Medicare, Medicaid or the Children’s Health Insurance Program (CHIP). Covered members are entitled to payment or reimbursement of their health care costs.
Health Insurance Marketplace
A federal government website where you can shop for health insurance, compare prices and buy plans from health insurance companies in your area. You can access the Marketplace at Healthcare.gov, through BCBSMT, or by phone.
HMO (Health Maintenance Organization)
A health plan that uses a network of doctors, hospitals and other providers who are part of the organization. An HMO can cost less than other plans, but it may not cover any of the costs of care by out-of-network doctors, hospitals or other providers. The only exception may be in case of a medical emergency.
Health Savings Account (HSA)
This type of savings account lets you put money aside tax-free to help pay for some health care costs like doctor visits and hospital bills. Once you set up your HSA, you can deposit money into it (up to a certain amount), then withdraw funds to pay for qualified medical expenses. Deductibles, copays and coinsurance are all expenses you can pay with HSA dollars. You don’t have to pay taxes on the funds you deposit or withdraw from your HSA.
HIPAA
Patient privacy is very important in health care. HIPAA stands for the Health Insurance Portability and Accountability Act. It is a law that protects your sensitive health and personal information from being shared with others without your permission. The law outlines rules health insurance plans must follow to protect their members' health information.
Home Health Care
Sometimes a doctor may have a nurse or other home health professional visit a patient at home. The visits might be to monitor an ongoing health condition or recovery after a hospital stay. The care provider may check on incisions after surgery or that prescription medicines are being taken correctly. They might gather blood pressure, heart rate, temperature readings. Home health care is designed to let people recover in the comfort of their own home while still getting care by a health professional.
Hospice Services
Hospice is a compassionate way of offering comfort and support to people in the last stages of a terminal illness. It doesn’t focus on curing illness or recovery. Instead, it is focused on reducing pain and controlling symptoms so patients can live as fully and comfortably as possible during their remaining days. Care may be given at the patient’s or relative’s home or in a hospice facility.
I
Individual and Family Out-of-Pocket Maximum
The most you have to pay for covered health care services in a one year. After the maximum is met, your health plan pays 100% of the cost for covered benefits. For example, an out-of-pocket maximum might be $6,000 for an individual policy and $18,000 for a family. The amount of the out-of-pocket maximum depends on the policy you choose. This limit never includes your monthly premium, balance-bill charges or health care your plan doesn’t cover. Some plans may not count all of your copays, deductibles, co-insurance, out-of-network costs or other expenses toward this limit.
Individual Coverage HRA (ICHRA)
Employers can offer individual health coverage through a Health Reimbursement Arrangement (HRA) instead of a group health plan. This type of coverage helps cover the cost for certain health care expenses such as monthly premiums, copays, deductibles and some out-of-pocket expenses.
Individual Health Insurance Policy
You may not have access to health insurance coverage through an employer or other group. An individual health insurance policy allows you to purchase your own health insurance policy. These policies are available through the Health Insurance Marketplace or can be purchased directly from an insurance provider. A variety of plans are available—including HMO and PPOs with choices of premiums, deductibles and out-of-pocket maximums.
Infusion Therapy
Some medicines are delivered in liquid form directly into the bloodstream. Chemotherapy is often an infusion therapy. Infusion drug care is sometimes also used to treat chronic conditions like asthma, immune deficiencies and rheumatoid arthritis. The drugs are often covered under a health plan's medical benefit, not its drug benefit.
In-Network
Health insurance companies negotiate with care providers to get the best possible prices for its members. Once a contract is in place, physicians, hospitals and other care providers are considered “in-network” because they agree to set prices for their services. When you see an in-network provider, your care costs are discounted. When you see an out-of-network provider, you pay higher out-of-pocket costs for your health care and may have to pay all the bill, depending on your plan.
Inpatient Care
Medical care received by anyone admitted to a hospital or skilled nursing facility.
Insured Person
The person who an employer or other insurer provides with health care coverage.
J
K
L
Lifetime Limit
A cap on the total benefits you get from your insurance company over the life of your plan. It could be a dollar limit on benefits such as a $1 million lifetime cap. It could be limits on specific benefits. For example, your plan may have a limit of one gastric bypass per lifetime. It could also be a combination of the two. After the lifetime limit is reached, the health plan no longer pays for services. There are no lifetime limits on essential benefits such as emergency services.
Long-term Care
Medical and non-medical care for people who are unable to do basic activities such as dressing or bathing without help. Long-term care can be provided at a person’s home, in an assisted-living facility or nursing homes. Medicare and most health insurance plans don’t pay for long-term care.
M
Medicaid
Free or low-cost health coverage to low-income individuals, families and children, pregnant women, the elderly and people with disabilities.
Medical Cost-Sharing Group
An organization – often a nonprofit – with members who share medical costs. Each member pays a set amount into a group fund every month. When a member gets a large medical bill, the fund pays some or all of that bill. Medical cost-sharing plans are not run by insurance companies and may have strict rules about who can participate.
Medical Group
A group of doctors and health professionals contracted as a group by a health plan to deliver care to plan members. Every provider in the medical group is considered in-network by your health insurance plan.
Medicare
A federal health insurance program that provides health care coverage to people 65 and older. Some younger people with disabilities can also get Medicare coverage.
Member
A person covered under a health plan – either as an enrollee or eligible dependent.
Minimum Essential Coverage (MEC)
Any insurance plan that meets Affordable Care Act requirements for coverage of basic health services, such as emergency care, prescriptions, lab or diagnostic services, and hospital stays.
N
Network
A group of doctors, hospitals and other health professionals paid to deliver care and cost savings to members.
Non-Contracting Hospital
A hospital that has no contract with a health plan to provide services to its members.
O
Open Enrollment Period
A period of time that allows people to sign up for a health plan. It usually takes place once a year.
Out-of-Network Care
Health services provided by a doctor or other care provider who is not contracted by your health plan. Out-of-network services may not be covered by your health insurance plan, or they may be covered at a lower level. You may be responsible for paying all or part of an out-of-network provider's bill.
Out-of-Pocket Costs
Costs you pay for medical care because it is not covered by your insurance. Deductibles, coinsurance and copays for covered services are examples. So are costs for non-covered services.
Out-of-Pocket Maximum
The most you have to pay for covered services during a policy period (usually one year).
Outpatient Care
Patient care that takes place in a hospital setting or outpatient center but doesn’t require an overnight stay.
P
Palliative Care
Palliative care is care at home that can be given at any time during a serious illness, such as cancer. Palliative care can be provided while the person with cancer is being treated to cure or control their cancer.
PPO (Participating Provider Option)
A type of health plan that uses a network of care providers who agree to provide services to the plan’s members for set prices. You can choose which providers in your network you want to see for care without a referral.
Pharmacy Benefit Manager (PBM)
A company that handles prescription drug benefits for health plans, Medicare Part D plans, large employers and other payers. PBMs negotiate prices with pharmacies and drug manufacturers. They help lower drug costs and save patients money.
Preferred Provider
A care provider who works with your health insurer to provide medical care and services at a discount. When you see a preferred care provider for a covered service or treatment, you save money on your health care by enjoying the highest reimbursement level.
Premium
The regular amount you pay (monthly, quarterly or yearly) to be covered by a health care plan.
Premium Tax Credit
A tax credit for dollars spent on health care costs. It is offered to individuals based on their income and family size. Unlike credits claimed when you file your taxes, the credit can be used right away to lower monthly premium costs.
Prescription Drugs
Medicines that must be ordered by a doctor and filled by a pharmacy. The drugs are reviewed and approved by the U.S. Food and Drug Administration (FDA).
Prescription Drug Payment Level Tier
A prescription drug list with “tiers" or levels. The tiers set how much a member pays out of pocket for the drug. Drugs in a lower tier cost less than drugs in a higher tier.
Preventive Care
Routine health screenings, check-ups and counseling to help fend off illness, disease and health problems.
Primary Care Provider (PCP)
The doctor, physician assistant or nurse practitioner you choose to be your first and main go-to for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Not all health plans require a PCP.
Prior Authorization (Also Preauthorization)
Sometimes a health care service, treatment, prescription drug or medical equipment must be approved before you receive it. This is done to make sure it’s medically needed. Being admitted to the hospital, medical testing and filling prescriptions are all examples. Without prior authorization, the service, treatment, drug or equipment may not be covered by your health plan.
Provider
A doctor, dentist, therapist or other health professional that delivers health care services. Imaging centers, infusion centers, urgent care centers, outpatient surgical centers and inpatient hospitals are types of facility providers.
Q
Qualified Health Plan
A health plan that meets the “minimum essential coverage” important to good health outlined by the Affordable Care Act.
Qualifying Life Event
An event that lets people sign up for health insurance outside the Open Enrollment period. If you get married, have a baby, move or lose your health coverage, you may be able to sign up during Special Enrollment.
Qualified Small Employer Health Reimbursement Arrangement
Small companies that can’t afford to provide group health coverage may offer employees this type of plan to help pay for monthly premiums and other health care costs. It’s a way for small businesses to attract and keep talented employees like bigger companies can, but on a small-employer budget.
R
Referral
A written order from your primary care doctor to see a specialist or get certain medical services. Many HMOs require a referral before you can get medical care from anyone other than your primary care doctor. If you don’t get a referral, the health plan may not pay for the services.
S
Skilled Nursing Care
Care and services given by a licensed nurse in your own home or in a nursing home.
Skilled Nursing Care Facility
Daily nursing care and rehab services given in a skilled nursing facility. Physical therapy and IV injections given by a registered nurse or doctor are examples.
Specialist
A health care provider who focuses on a specific area of medicine. They are experts on a certain body system, disease, treatment and patients.
Special Enrollment Period
A time outside open enrollment when a person can sign up for health insurance. It kicks in for 60 days after a person has a qualifying life event. Marriage, birth of a child, a move and loss of health coverage are among these events.
Specialty Drug
A prescription drug to treat complex health conditions. They often have special handling needs and are not normally sold in retail pharmacies.
State Continuation Coverage
Some states require small companies with less than 20 people to offer COBRA-like health care coverage to individuals who lose their job. Dependents of the laid-off workers may also be covered. The temporary health care coverage may last 12 months or longer, depending on the state.
Subsidy
A tax credit for dollars spent on health care. It is offered to individuals based on their income and family size. Unlike credits claimed when you file your taxes, the credit can be used right away to lower monthly premium costs.
Summary of Benefits and Coverage (SBC)
An overview that lets you compare costs and coverage of health plans. Compare plans by price, benefits, or other features. You'll get a summary when you shop for health plans on your own or through your job. You’ll also get a summary when you renew or change coverage—or request it from the health insurance company.
T
Telehealth/Telemedicine
Some doctors and therapists can conduct your health visit over the phone or by video chat. If your health plan covers these services, you may get medical care from a doctor in your network or by using a telehealth service offered by your plan.
Teledentistry
Some dental plans may cover teledentistry. This allows you to meet with a dentist over the phone if you have an urgent dental issue outside business hours, or when away from home.
U
Urgent Care
Medical aid for an illness, injury or condition that needs care right away, but isn’t serious enough to go to the emergency. An ear infection, fever or vomiting are examples of illnesses that can be treated at an urgent care.
Utilization Management
A review process that looks at the type and amount of care you get. It focuses on the setting for your care and its medical necessity.
V
Virtual Visits
Another term used to refer to telehealth, telemedicine and teledentistry.
W
Waiting Period
The time before coverage goes into effect for an employee or dependent covered under a job-based health plan.