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.

Coinsurance

The dollar amount or percentage you pay for your covered health care services. For example, if you have an “80/20”  plan, your health plan would pay 80 percent of the bill and you would pay 20 percent. The 20 percent you pay is your coinsurance.

Copayment

A set dollar amount you pay each time you receive a health care service. For example, your health plan may have a $20 copayment for a doctor’s office visit. You will pay this amount each time you go to the doctor.

Deductible

The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.

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.

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 benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.

Non-embedded Deductible

If you select a Blue Option plan with a non-embedded family deductible, there is not an individual deductible embedded in the family deductible. You must meet the entire amount of the deductible before your plan will pay any benefits. One family member or a combination of family members can meet the deductible.

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.

Summary of Benefits and Coverage (SBC Glossary)