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See also Dual Coverage

Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.

Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.

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

See also: Generic Drug.

A program that assists the member-patient in determining the most-appropriate and cost effective treatment plan. Case management is usually provided to patients who have prolonged expensive or chronic conditions. The program helps determine the treatment location (hospital, other institution or home) and may authorize payment for such care if it is not covered under the member’s benefit agreement.

An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.

Q41. What is the difference between deductibles and co-payments?
A41. Co-payment is a type of member cost sharing that requires a flat amount per unit of service or unit of time. This is may be a percentage of the charges or a dollar amount for specified services. 

Deductible is an amount the insured person must pay before benefit payments for covered services begin. The deductible is usually a set amount or a percentage determined by the member's contract. For example, a plan might require the insured to pay the first $500 of covered expenses during a calendar year before any benefits are payable.


Q42. How does my out-of-pocket maximum work?

A42. Out-of-pocket maximum refers to the most you pay for covered expenses during the year before your plan begins paying 100% of covered expenses for the remainder of the year. It is a sum of deductible and coinsurance amounts. Only covered expenses, as determined by your contract, count toward the maximum. Other costs, such as amounts you pay for non-covered services or charges in excess of our allowances, don?t count.

Blue Cross FAQ's

Consolidated Omnibus Budget Reconciliation Act: a federal law that requires most employers with 50 or more employees to provide continuation of coverage for members as prescribed by current federal law.

An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, a health plan might pay 80% of the allowable charge, with the enrollee responsible for the remaining 20%; the 20% amount is then referred to as the coinsurance amount.

Q42. How does my out-of-pocket maximum work?

A42. Out-of-pocket maximum refers to the most you pay for covered expenses during the year before your plan begins paying 100% of covered expenses for the remainder of the year. It is a sum of deductible and coinsurance amounts. Only covered expenses, as determined by your contract, count toward the maximum. Other costs, such as amounts you pay for non-covered services or charges in excess of our allowances, don?t count.

Blue Cross FAQ's

The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.

Q41. What is the difference between deductibles and co-payments?
A41. Co-payment is a type of member cost sharing that requires a flat amount per unit of service or unit of time. This is may be a percentage of the charges or a dollar amount for specified services. 

Deductible is an amount the insured person must pay before benefit payments for covered services begin. The deductible is usually a set amount or a percentage determined by the member's contract. For example, a plan might require the insured to pay the first $500 of covered expenses during a calendar year before any benefits are payable.

Blue Cross FAQ's

Many plans offer a provision called a deductible carryover. This provision allows you to carry over to the next year any unmet portion of the deductible that you, or your family, run up in October, November and December. For example, assume you had no medical claims in the first part of the year. In November, you run up $350 worth of claims. If your deductible was $500, you would start the next year with $350 of your $500 deductible already meafchealth.com/

Glossary - Annuity Advisors LOMA

A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. See: /general/plans/supplemental/drug.asp

An injury or sudden, unexpected illness (including severe pain and active labor) of sufficient severity that if the member does not receive immediate treatment, it could present a serious threat to his or her health, could seriously impair physical functions, or could cause a serious dysfunction of any organ or body part if immediate medical treatment is not received.

An individual who is enrolled and eligible for coverage under a health plan contract. This term encompasses both the subscriber and any of his/her covered dependents, each of whom may also be referred to as a "Member".

See also: Member.

Specific conditions or circumstances that are not covered under the health plan benefit agreement. It is very important to consult the health plan benefit agreement (may also be called the Evidence of Coverage, Certificate, or Subscriber Contract) to understand what services are not covered benefits.

A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, and the claims appeal process.

From Page 2 of Blue Shields Individual 50 Page Brochure

A card issued to a subscriber and possibly his/her dependents, which allows the subscriber to identify himself or his covered dependents to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.

Immunizations and injections that are recommended by guidelines published by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service or the American Academy of Pediatrics (AAP).

The Knox-Keene Health Care Service Plan Act of 1975, as amended, is the set of laws passed by the State Legislature to regulate HMOs within the State 

 MemberAn individual or dependent who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

See also: Enrollee.Mental Health / Behavioral Health Conditions that affect thinking and the ability to figure things out and that affect perception, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking or distortions of the way things are perceived (seeing or hearing things that are not there.) Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, and highly agitated or unusual behavior.  Click here for Information on the Mental Health Parity Act 

This means that you pay the full cost of ... care (at our negotiated rates) until your annual deductible has been met. Health Net Brochure page 9

Balance Billing

If it seems too good to be true, it probably is. Nationwide, the health insurance marketplace is facing tough times. The cost of health insurance is rising. Those seeking to make a profit by selling fraudulent health insurance claim that state insurance laws don’t apply. These entities recruit insurance agents to sell "ERISA plans" or "union plans" that falsely claim to be exempt from state law. Click on link to find information from  National Association of Insurance Commissioners (NAIC) to help you protect yourself against illegal health insurance plans DOL Site on MEWA DOL Investigations & Enforcement

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) coverages can go out-of-network, but will pay some additional costs.

See also: Health Maintenance Organization (HMO), Network, Point of Service (POS), Preferred Provider Organization (PPO).

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Applies to specified services that require review and approval prior to the expense for such services being incurred. If a service is not Pre-Certified, benefits paid for that service will be reduced in accordance with the provisions of your Certificate of Insurance or Evidence of Coverage.

See also HMO

See also late enrollee Qualifying Event

New company formed by employees leaving an established group to form a new company with a new owner, and potentially, some additional employees who are not from the established group. If two or more employees they are GUARANTEED issue under Ins. Code 10700

Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or sever pain, such as a high fever. urgent

A "usual" charge is the amount that is most consistently charged by an individual physician for a given service. A "customary" charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A "reasonable" charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under an UCR Program, the payment is the lowest of the actual billed charge, the physician's usual charge or the area customary charge for any given covered service.

See also: Customary and Reasonable (C&R).

The entire program of systems designed to ensure that members receive quality, medically necessary health care services at the appropriate level of care in a timely, effective, and cost efficient manner. It includes pre certification, concurrent review, discharge planning, care management and retrospective review.