- 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.
The approval of medically necessary care by a managed care or insurance company.
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.
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 allowed amount, and you would pay 20 percent. The 20 percent you pay is your coinsurance amount.
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 in-network doctor.
- Covered Service
Medical service that your health plan will pay for.
We outline covered services in your Schedule of Benefits or Certificate of Coverage.
The amount you must pay for covered services before your health plan starts to pay. For example, say 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
Your plan contains two components — an individual deductible and a family deductible.
Once a family member meets his or her individual deductible, the plan will cover that family member’s covered medical expenses.
Once family members have reached the family deductible, the plan will pay for covered expenses for all family members. The individual deductible is embedded in the family deductible.
- Essential Health Benefits
A set of 10 categories of services health insurance plans must cover, including:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
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 benefits 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 qualified medical expense for the essential health benefits.
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 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.
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 2023 begins November 1, 2022.
- 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.
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)
An 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.