Health Insurance glossary

Balance Billing

Billing a member for the difference between the allowed charge and the actual charge. See Allowed Benefit.

Basic Coverage

Hospital and medical coverage only -- does not include extended medical, major medical, dental and rider coverage. Also includes Medicare Part A and B coverage, exclusive of supplementary coverage.

Behavioral Health Services

See "Mental Health Services."

Benefit

Any service or supply covered by the member's health insurance plan or contract.

Benefit Period

A period of time for which covered services (or benefits) are eligible for payment.

Benefits Administrator

Individual responsible for handling employee health benefits for the employer. See Group Administrator.

BlueChoice

An HMO plan offered by CareFirst BlueChoice, Inc., an independent licensee of the BlueCross BlueShield Association.

Brand-name Drug

A prescription drug that has been patented and is only available through one manufacturer.

Carrier

Commercial insurance company, a BlueCross and BlueShield plan or a Medicare claims agent.

Carve-out Benefits

Coverage stipulating that Medicare-eligible members of a group receive benefits at least equal to benefits received by non-Medicare group members. Members are reimbursed up to the group's contract limitations, less what Medicare paid or would have paid if the member were Medicare-eligible and Medicare were the primary coverage.

Case Management

A coordinated set of activities designed to assist a member in managing specific health care needs.

Certificate of Coverage (COC)

A summary detailing the terms, conditions and limitations of your group coverage that is issued to the group.

Certification

See Pre-Authorization.

Chemotherapy

Treatment of malignant disease by chemical or biological antineoplastic agents. High-dose chemotherapy is a type of chemotherapy often used in conjunction with tissue transplants.

Chiropractic Care

A therapy administered by a licensed Chiropractor that involves manipulation or adjustment of the spine.

Chronic Care

Inpatient or outpatient services provided to patients who suffer from a prolonged illness.

Claim

A request for payment for benefits received or services rendered. Either the member or the provider submits claims to the carrier.

COBRA - Consolidated Omnibus Budget Reconciliation Act of 1986

Federal legislation that includes a requirement for groups with 20 or more employees to offer extended health insurance coverage at the member's expense to members and eligible dependents who leave the group or are otherwise no longer eligible for the group's coverage.

Coinsurance

The percentage or amount patients are required to pay through their insurance plan for reasonable medical expenses after a deductible has been satisfied.

Continuation

Local or federal legislation that includes a requirement for groups to offer extended health insurance coverage at the member's expense to members and eligible dependents who leave the group or are otherwise no longer eligible for the group's coverage. See COBRA - Consolidated Omnibus Budget Reconciliation Act of 1986.

Continuity of Coverage

Procedure by which individuals transferring from one insurance plan to another are allowed uninterrupted coverage from the date of original enrollment.

Contraception

Methods, drugs or devices for preventing pregnancy.

Contract

A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.

Contract/Certificate Holder

Group or person to whom a contract or certificate is issued.

Conversion

Change in a customer's contractual status. For example, transfer from group to direct payment coverage upon termination of employment.

Conversion Option

The choice to purchase individual coverage by a person who is leaving an employee group.

Coordination of Benefits (COB)

Contractual provision which reduces the benefits under one contract to the extent that those benefits are available under a second contract. The purpose is to prevent double payment for one service. See Duplicate Coverage.

Copayment

The dollar amount a patient pays when services are received. A visit to a primary care physician might require a copayment of $10, a visit to a specialist $20 and a prescription $20.

Cosmetic

A term that describes the use of a service or supply which is provided with the primary intent of improving appearance, not restoring bodily function or correcting deformity resulting from disease, trauma or previous therapeutic intervention.

Cost Sharing

Health insurance policy provisions that require insured individuals to pay some portion of covered medical expenses. Examples are deductibles, coinsurance and copayments.

Covered Person

Person, including eligible dependents, entitled to benefits under the contract and also known as the "insured."

Covered Services

Applies to services or supplies specified in the contract for which benefits are available under the member's plan.

Custodial Care

Care which is provided primarily to meet the personal needs of the patient. Custodial Care does not require the continuous attention of skilled medical or paramedical personnel. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine or any other care that does not require continuing services of medically trained personnel.

Day Treatment Center

An outpatient psychiatric facility or hospital which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.

Deductible

The dollar amount of covered services based on the allowed benefit that must be paid by an individual or family per benefit period before the insurance company (CareFirst) begins to pay its portion of claims.

Dental Care

Routine preventive and treatment of teeth and the structures directly supporting the teeth. Generally, dental care is not covered by the health benefit plan.

Dependent(s)

A member who is covered as the spouse, eligible child or grandchild of a subscriber (the employee).

Diagnostic Tests

Medically necessary test(s) and/ or non-surgical procedure(s) ordered by a physician/ dentist to determine if the patient has a certain condition or disease. Such diagnostic tools include radiology, laboratory, pathology services or tests.

Disease Management

Programs for members with chronic health conditions. Services range from quarterly mailings to case management with 24-hour access by phone to a support nurse.

Drug Formulary

See "Formulary."

Duplicate Coverage

Enrollment of one person for the same type of benefits under more than one contract. See "Coordination of Benefits (COB)."

Durable Medical Equipment (DME)

Goods, implements, prosthetics, etc., that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

Effective Date

Date on which a group member's coverage begins, typically occurring at the end of an eligibility period stipulated by the group.

Elective Surgery

Surgery for a condition that is not considered an emergency.

Eligibility

Insured person's qualification for coverage as an eligible member under the contract at the time health care is rendered.

Eligibility Period

Period of time before a group member becomes eligible for benefits. This is defined by each group.

Emergency Care

Care for patients with severe or life-threatening conditions that require immediate intervention.

Emergency Surgery

Procedure that must be performed in a situation that is serious or life-threatening for the patient.

Enrollee

An individual who is enrolled and eligible for coverage under a health plan contract. Also known as the "insured."

Enrollment

Process by which a person completes an enrollment form or application in order to become a member of health insurance coverage under a contract.

Evidence of Coverage (EOC)

A summary detailing the terms, conditions and limitations of your group coverage.

Exclusion

Specific circumstances or services listed in the contract for which benefits will not be provided.

Experimental Procedures

Any service or supply that is in the developmental stage or is in the process of human or animal testing.

Expiration Date

See "Termination Date."

Explanation of Benefits (EOB)

A statement a member receives that describes how a claim was processed for benefits, including the member's liability for services rendered.

Family Deductible

The amount of annual deductible required to be paid when there are two or more family members on the policy. Many CareFirst BlueCross BlueShield policies limit the annual family deductible to two times the individual deductible.

Family Membership

Provides coverage for a husband, wife, and children or grandchildren, or a single parent with one or more children. Each additional child can be added to the family membership at no extra cost. Eligibility rules for children over 18 vary by plan and area, as do eligibility rules for grandchildren.

Fee-for-Service Payment System

A system in which the insurer will either reimburse the group member or pay the provider directly for each covered medical expense after the expense has been incurred.

Formulary

A formulary is a list of covered prescription drugs. Our drug list is reviewed and approved by an independent national committee comprised of physicians, pharmacists and other health care professionals who make sure the drugs on the formulary are safe and clinically effective. The prescription drugs found on the CareFirst Formulary (drug list) are divided into tiers. These tiers include no cost drugs, generics, preferred brand, non-preferred brand, preferred brand specialty, and non­preferred brand specialty drugs. Your cost share is determined by the tier the drug falls into.

Generic Drug

A drug which is the pharmaceutical equivalent to one or more brand name drugs. The Food and Drug Administration has approved such generic drugs. They meet the same standards of safety, purity, strength and effectiveness as the brand name drug.

Generic Substitution

When an FDA-approved generic equivalent (Tier 1) is substituted for a non-preferred brand name drug (Tier 3).

Group

The employer company, organization or association that contracts with your insurance company to provide health benefits to eligible employees and their dependents.

Group Administrator

Individual responsible for handling employee health benefits for the employer.

Group Contract (GC)

A legal agreement between an employer group and a health plan that describes the benefits and limitations of the coverage.

Group Contribution/Employer Contribution

Portion of premiums that an employer or other group entity pays toward the cost of its members' and/or dependents' coverage.

Group Number

Group-specific identification number.

Habilitative Services

Those services that include occupational, physical and speech therapy and select oral health care for the treatment of children with certain congenital or genetic birth defects, to enhance the child's ability to function. These services are directed at developing skills that were never present.

Health Benefit Plan

The health insurance product offered by a health insurance company. It is defined by the benefit contract and represents a set of covered services and a provider network.

Health Insurance Portability and Accountability Act (HIPAA) of 1996

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was designed to streamline all areas of the health care industry and to provide additional rights and protections to participants in health plans.

Health Maintenance Organization (HMO)

A health benefits program that usually has the lowest out-of-pocket costs. HMOs require that the member select a primary care physician, generally a family practitioner, internist or pediatrician, who is part of the plan's network. There are generally small copayments and no claims to file. In an HMO, a referral is required from the primary care physician to see any specialist in its network except an OB/GYN.

Hearing Services

Services related to the hearing structures of the ear.

HealthyBlue 2.0

HealthyBlue 2.0, also known as Standard HealthyBlue, is an enhanced, innovative health care plan that offers cost savings, ease of use and gives you greater control of your health and access to health care.

HMO

See "Health Maintenance Organization (HMO)."

Home Health Care

Skilled nursing and related health services provided by home health agencies to patients in a home setting. Services may also include physical therapy, occupational therapy, speech therapy, medical social services, home nursing services and provision of medical supplies and equipment.

Home Infusion Therapy

The administration of intravenous drug treatment in the home.

Hospice

Program or facility that provides medical care and support services for terminally ill patients and their families. The hospice provides services either directly or on a consulting basis with the patient's physician or a community agency.

Hospital

An institution whose primary function is to provide inpatient, diagnostic and therapeutic services. The services are for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

Identification Card

Document issued to a covered member confirming his or her eligibility to claim benefits.

Immunizations

Vaccines against certain diseases, which can be administered either orally or by injection.

In-Network

Refers to the use of providers who participate in the health plan's provider network. Many benefit plans encourage members to use participating in-network providers to reduce out-of-pocket expenses. See "Out-of-Network."

Incidental Procedures

Procedures carried out at the same time as a primary procedure that are clinically integral to the performance of the primary procedure. A participating provider has contractually agreed to write-off the charges.

Indemnity Plan

Provision of specific cash payment reimbursement for designated covered services. Payments are made either to the member or directly to a participating provider.

Independent or Individual Practice Association (IPA)

A type of organization which contracts with individual providers or groups of providers to arrange for the provision of their professional services to enrollees of a Health Maintenance Organization (HMO).

Infertility

Term used to describe the inability to become pregnant after a year or more of regular sexual relations without the use of contraception.

Infusion Therapy

Treatment that places therapeutic agents into the vein, including intravenous feeding.

Inpatient

Person admitted to the hospital to receive hospital services, including room, board and general nursing care.

Insured

Person, including dependents, covered by a contract. Also known as "covered person" or "member."

Investigational Procedures

See "Experimental Procedures."

Lifetime Maximum

The maximum amount the plan will pay in benefits for each member during their lifetime.

Limitation

Specific circumstances or services listed in the contract for which benefits will be limited.

Mail Order Program

Used as an alternative to retail pharmacies, members can order and refill their prescriptions via postal mail, Internet, fax or telephone. Once filled, the prescriptions are mailed directly to the member’s home.

Maintenance Drug

A medication that is anticipated to be taken regularly for several months to treat a chronic condition such as diabetes, high blood pressure or asthma.

Managed Care

A general term for organizing doctors and hospitals into health care delivery networks with the intent of lowering costs and managing the medical care provided. HMOs were the earliest form of managed care. Today there are many different kinds of plans, including Preferred Provider Organization (PPO) plans.

Mandated Benefits

Specific component of health care coverage required by state or federal government.

Maternity Care

The care and treatment related to pregnancy and delivery of a newborn child.

Maximum Annual Copayment

The limit on the amount of money a member spends in copayments in a calendar year for covered in-network expenses.

Medical Equipment

See "Durable Medical Equipment (DME)."

Medical Underwriting

The process of reviewing each applicant's personal health history and current health status to determine enrollment eligibility.

Medically Necessary

The term "medically necessary" describes the use of a service or supply which is: commonly and customarily recognized as appropriate in the diagnosis and treatment of a member's/ subscriber's illness or injury; appropriate with regard to standards of good medical practice; not solely for the convenience of the member/subscriber, his or her physician, hospital or other health care provider; and the most appropriate supply or level of service which can be safely provided to the member/subscriber.

Medicare

Title XVIII of the Social Security Act, which provides health care benefits to Social Security pensioners 65 and older and to eligible disabled individuals.

Medicare Approved Charge

Amount on which Medicare bases its payment for medical services. It is the lower of either Medicare's fee schedule or the doctor's or supplier's actual charge for a service or supply.

Medicare Eligible Employees

All eligible employees over 65 that are not TEFRA eligible, as well as any retirees over 65. Medicare would be the primary coverage for these individuals.

Medicare Supplement Contract

Health insurance plan available to Medicare eligibles to cover the costs of physicians' services and other medical and health services not covered by Medicare.

Medicare (Part A)

Part of the Medicare law providing benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment.

Medicare (Part B)

Part of the Medicare law providing medical-surgical benefits to Medicare beneficiaries for a modest premium.

Medigap

See "Medicare Supplement Contract."

Member

An eligible individual who is enrolled in an insurance plan. A member may be a subscriber or a dependent.

Mental Health Services

Services primarily to treat any disorder that affects the mind or behavior.

Network

A group of multi-specialty medical groups and individual practice doctors that are contracted to provide services to members of a health plan.

Network Provider

A medical provider who has contracted with a health plan as a participating provider.

Non-Participating Provider

A medical/dental provider who has not contracted with a particular health plan within its participating provider network. The member is responsible for the total charge for services rendered. See "Participating Provider."

Not Medically Necessary

Describes the use of a service or supply which does not meet the criteria for determining medical necessity. See "Medically Necessary."

Occupational Therapy

Treatment of a physically disabled person by means of constructive activities designed and adapted to promote restoration of the person's ability to perform activities of daily living and those tasks required by the person's particular occupation or role. It is not recreational or diversionary therapy.

Open Enrollment

Designated period of time during which an employee may enroll in group health coverage. Also, designated period of time during the year when individuals without group coverage may enroll in health coverage without needing medical underwriting.

Out-of-Network

The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in Preferred Provider Organizations (PPO) and Point-of-Service (POS) plans can go out-of-network, but will pay higher out-of-pocket costs. See "In-Network."

Out-of-Pocket Limit or Out-of-Pocket Maximum

The maximum dollar amount a member will pay out-of-pocket in coinsurance, copays and/or deductibles in a calendar year for covered indemnity expenses. Once the out-of-pocket limit is met, the plan pays 100% of the allowed amount for covered services for the rest of the benefit period.

Outpatient

Patient who receives hospital care without being admitted as an inpatient.

Outpatient Surgery

Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, surgery center or physician's office.

Partial Day Treatment

A program offered by licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.

Participating Provider

Individual physicians, hospitals and professional health care providers who have a contract with CareFirst BlueCross BlueShield and/ or CareFirst BlueChoice, Inc. to provide services to its members at a discounted rate and to be paid directly for covered services. See "Non-Participating Provider."

PCP

See "Primary Care Physician (PCP)."

Physical Therapy

Treatment by a licensed therapist involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.

Plan Allowance (Allowed Amount or Allowable Charge)

The maximum dollar amount a contract allows for services covered, regardless of the provider's actual charge. A provider who participates in the network cannot charge the member more than this amount for any covered service.

Plan Benefit Maximum

See "Lifetime Maximum."

Point-of-Service (POS) Plans

These plans include in-network (HMO) and out-of-network (PPO or traditional major medical) options that enable members to select which network and level of benefits they want to utilize at the time services are required.

Policyholder

The employee or member of a group who applies for coverage or applies for coverage on an individual, or has a non-employer-sponsored contract and is the person whose name is on the contract.

Pre-Authorization

Approval necessary for designated procedures or hospital admissions. When care is received in-network, the primary care physician or specialist is usually responsible for obtaining pre-authorization. For out-of-network services, the member is responsible for obtaining pre-authorization.

Pre-Certification

See "Pre-Authorization."

Pre-Existing Condition

An illness or condition that you or another member had prior to applying for health insurance. In some cases, these conditions may be subject to a waiting period for benefits or excluded from coverage.

Preferred Drug List

Also known as a formulary, this is a list of certain brand name and covered generic prescription drugs. The preferred drug list was developed and is maintained by the CareFirst BlueCross BlueShield Pharmacy and Therapeutics Committee, which is made up of a group of physicians and pharmacists that practice in the CareFirst BlueCross BlueShield region. CareFirst BlueCross BlueShield may change this list from time to time to provide the most cost-effective and complete prescription drug options to members. See "Formulary."

Preferred Provider Organization (PPO)

An agreement between a medical provider and a health care carrier for the delivery of services to a specific member population using discounted fees for cost savings. This relates to only a fee arrangement, and does not imply that any provider is more or less qualified than another.

Premiums

Periodic amounts paid by or on behalf of members for ongoing health care coverage. It does not include any deductibles or copayments the plan may require.

Prescription

A written order or refill notice issued by a licensed medical professional for drugs or devices (e.g., syringes, needles for diabetics) that are only available through a pharmacy.

Preventive Care

Care rendered by a physician to promote health and prevent future health problems for a member who does not exhibit any symptoms. Examples are routine physical examinations and immunizations.

Primary Care Physician (PCP)

A physician selected by the member, who is part of the plan network, who provides routine care and coordinates other specialized care. The PCP should be selected from the network that corresponds to the plan in which you are a member. The physician you choose as your PCP may be a family or general practitioner, internist or pediatrician.

Prior Authorization

See "Pre-Authorization."

Prior Authorization List

This is a list of brand name and generic prescription drugs developed and maintained by CareFirst BlueCross BlueShield and used by providers and pharmacists when writing and filling prescriptions. Prior Authorization is used to insure the appropriate use of medications that have specific indications, safety concerns, or have a high potential for overuse.

Prosthetic Devices

A device which replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.

Provider

Person, organization or institution licensed to provide health care services.

Provider Network

The set of providers contracted with a health plan to provide services to the members. In the case of a fee-for-service or non-network health plan, the provider network is generally all licensed providers of covered services.

Radiation Therapy

Treatment of disease by X-ray, radium cobalt or high-energy particle sources.

Reconstructive

A term that describes procedures performed on structures of the body to improve or restore bodily function or to correct deformity resulting from disease, trauma or previous therapeutic intervention.

Referral

A written recommendation by a physician that a member may receive care from a specialty physician or facility.

Respiratory Therapy

Treatment to improve or preserve lung function.

Rider

Provision added to a contract, which increases or limits benefits or coverage.

Schedule of Allowances

List of dollar amounts payable for medical and surgical procedures performed by a provider.

Second Opinion

The option or recommendation to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

Second Surgical Opinion (SSO)

Included among the features of Medical Management programs, SSO provides coverage for a second opinion from a qualified surgical specialist to group members seeking elective surgery. Mandatory SSO requires that group members seek the second opinion.

Self-Insurance

Practice of an individual, group of individuals, employer or organization that assumes complete responsibility for losses, which might be insured against, such as health care expenses. In effect, "self-insured" groups have no real insurance against potential losses and instead maintain a fund out of which is paid the contingent liability subject to self-insurance.

Service Area

The geographic area in which a health plan delivers health care through a contracted network of participating providers.

Skilled Nursing Facility (SNF)

A licensed institution (or a distinct part of a hospital) that provides continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.

Specialist

A participating physician who provides non-routine care, such as a dermatologist or orthopedist.

Speech Therapy

Treatment of the correction of a speech impairment, which resulted from birth, disease, injury or prior medical treatment.

Standard HealthyBlue

Also known as HealthyBlue 2.0, an enhanced, innovative health care plan that offers cost savings, ease of use and gives you greater control of your health and access to health care.

Subscriber

The employee or member of a group who applies for coverage or applies for coverage on an individual, or has a non-employer-sponsored contract and is the person whose name is on the contract. See "Policyholder."

Substance Abuse/Chemical Dependency

The use of any drug for purposes other than those for which it is normally intended or in a manner or in quantities other than directed. Chemical dependence is the compulsion to continue taking a drug to produce desired effects or to prevent the onset of ill effects that occur when it is not taken.

TEFRA (Tax Equity and Fiscal Responsibility Act of 1982)

Requires employers with 20 or more employees to offer active employees and their spouses aged 65-69 the same level of health care benefits offered to younger employees. These employees will have their regular group coverage as primary and Medicare as secondary.

Termination Date

The date indicated in an insurance contract as the date coverage expires.

Three-Tier Prescription Drug Benefit

A benefit option in which a member pays a lower copay for generic drugs (Tier 1), a higher copay for preferred brand name drugs (Tier 2) and the highest copay for non-preferred brand name drugs (Tier 3). See "Formulary."

Traditional Insurance

See "Fee-for-Service Plans."

Urgent Care

A condition that requires prompt medical attention, but is not a threat to life or limb.

Utilization Management

Managing the use of medical services to ensure that a patient receives necessary, appropriate high-quality care in a cost-effective manner.

Utilization Review

The evaluation of the medical necessity, efficiency and/or appropriateness of health care services and treatment plans.

Well Baby/Well Child Care

Routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six.

Wellness Program

A health management program which incorporates the components of disease prevention, medical self-care and health promotion.