Glossary

Affordable Care Act (ACA)

The health care reform law. This law was passed in two parts. The Patient Protection and Affordable Care Act became law on March 23, 2010. This law was amended by the Health Care and Education Reconciliation Act on March 30, 2010. ACA refers to the final, amended version of the law. Some people also call this law Obamacare.

Allowed Amount

The dollar amount that a health plan determines is appropriate for a covered service. Blue Option network health care providers have agreed to accept the allowed amount as full payment (minus applicable copayments), which means you pay less for your care.

Authorization

The approval of medically necessary care by a managed care or insurance company.

Benefit

Payment provided for covered services under the terms of the policy. The benefit may be paid to the member or to others on the member’s behalf.

Coinsurance

Percentage of covered expenses that the member must pay. For example, if your physician charges $100 for a service and your health plan has a 20 percent coinsurance payment, you would be responsible for paying $20 of the charges and your health plan would pay $80.

Copayment

A specific amount of money you pay for certain services, such as office visits or medications, each time you use that service, as your plan defines. For example, if your health plan has a $15 copayment for an office visit, you would be responsible for paying $15 every time you visit your doctor’s office.

Covered Service

Medical service that your health plan will pay for. We outline covered services in your Schedule of Benefits or Certificate of Coverage.

Deductible

The amount of medical expenses that the member must pay during a particular period (usually a year) before certain benefits payable by the health plan become effective. For instance, if your health plan has a $200 deductible per 12-month period, you would be responsible for paying $200 worth of covered medical services within 12 successive months before your health plan would begin reimbursing for covered services. Please note that coupons for medical services and/or prescription drugs may not be used to satisfy the deductible when a generic prescription drug is available.

Embedded Deductible

If you select a Blue Option family plan with an embedded deductible, your plan contains two components – an individual deductible and a family deductible. Once a family member meets his or her deductible, then the plan will cover that family member’s covered medical expenses. Once family members have reached the family deductible, then the plan will pay for covered expenses for all family members. The individual deductible is embedded in the family deductible.

Exclusions

Specific conditions or circumstances the contract does not cover.

In-Network Care

Refers to services you receive from physicians who participate in the Blue Option network.

Maximum Out of Pocket (MOOP)

The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefi ts that are provided by in-network providers. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualifi ed medical expense for the essential health benefi ts. This limit does not have to count premiums, balance billing amount for non-network providers, health care your plan doesn’t cover or coupons for medical services and/or prescription drugs when a generic prescription drug is available.

Medically Necessary

Health care services and supplies that are appropriate and necessary based on diagnosis and cost-effectiveness, and are consistent with national medical practice guidelines as to type, frequency and length of treatment.

Network

The hospitals, physicians and other medical professionals who contract with BlueChoice HealthPlan in the Blue Option network to provide care for you. Also referred to as participating or in-network providers.

Network Provider

Network providers are doctors, hospitals and other health care providers that we have contracted with to provide health care services to our members. Network providers are also called “in-network” providers or “participating” providers.

Open Enrollment Period

The yearly period when you can enroll in or make changes to your health insurance coverage. Open enrollment for 2020 runs from Oct. 15, 2019 to Dec. 15, 2019.

Out-of-Pocket Costs

Your costs for health care that your health plan doesn’t pay. Depending on your plan, this may include your deductible, coinsurance and copayments for covered services.

Out-of-Network Care

Services you receive from physicians who do not participate in the Blue Option network.

Participating Providers

Physicians, hospitals, skilled nursing facilities, home health agencies, hospices and other providers of medical services and supplies who agree to participate in the Blue Option provider network.

Primary Care Physician

Doctors who provide primary care include pediatricians, family medicine doctors and internal medicine doctors. The physicians usually treat the whole person and may provide preventive care and routine checkups, as well as sick care or treatment of chronic illnesses.

Referral

When your doctor sends you to a specialist or health care facility to get certain health care services. Some health plans require you to get this from your primary care physician.

Special Enrollment Period (SEP)

A special enrollment period (SEP) is a time outside of the yearly open enrollment period when you can enroll in a health insurance plan. You qualify for an SEP if you’ve had certain life events like losing health coverage, moving, getting married, having a baby or adopting a child.