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Glossary of Terms

A

Affordable Care Act

A new, comprehensive law passed in 2010, aimed at reforming America's health care system to improve access and affordability for more Americans.

annual deductible

The amount you are required to pay annually before reimbursement by your health care plan begins. Not all plans require an annual deductible.

annual limit

An insurance plan may limit the dollar amount it will pay during one year for a certain treatment or service, or for all benefits provided in a year.

annual out-of-pocket maximum

The maximum amount, per year, you are required to pay out of your own pocket for covered health care services. The annual out-of-pocket amount may or may not include a deductible.


B

benefits

The health care items or services covered by an insurance plan. Your insurance plan may sometimes be referred to as a "benefit package."


C

catastrophic plan

The health insurance exchange will include a catastrophic plan option. Catastrophic plans have lower premiums, but begin to pay only after you've first paid a certain amount for covered services, or just cover more expensive levels of care, like hospitalizations. Catastrophic plans are an option to consider for young adults and people for whom coverage would otherwise be unaffordable.

claim form

A form you may have to fill out and submit to your health insurance carrier for payment of benefits under that health care plan.

claim

An itemized bill for services that have been provided to a subscriber, a subscriber's spouse or dependents.

claim form

A form you may have to fill out and submit to your health insurance carrier for payment of benefits under that health care plan.

COBRA

A federal act (Consolidated Omnibus Budget Reconciliation Act of 1985) which requires group health care plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event which causes the loss of group health coverage. Qualifying events include reduced work hours, termination of employment, a child becoming and over-aged dependent, Medicare eligibility, death or divorce of a covered employee.

coinsurance

A percentage of a covered charge that you are required to pay toward a service covered by your plan. Not all plans require coinsurance.

Coordination of Benefits (COB)

An arrangement where, if you or your dependents are covered under more than one health care plan, the plans work together to coordinate reimbursement for benefits you receive.

copayment

A fixed dollar amount you are required to pay for a service at the time you receive care. Not all plans require copayments.

covered service

A service that is covered by your health care plan.


D

deductible

A fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins.

dependent

A person, other than the subscriber (generally a spouse or child), who receives health care coverage under the subscriber's health care plan.

domestic partner

A person with whom the member has entered into a long-term, committed relationship. The relationship must meet the health care plan's specific criteria for a domestic partnership.

drug list

A list of commonly prescribed drugs (also known as a prescription drug formulary). Not all drugs on a plan's prescription drug list are automatically covered under that plan.


E

employer responsibility

Starting in 2015, if an employer with at least 50 full-time equivalent employees doesn't provide affordable health insurance and an employee uses a tax credit to help pay for insurance through a Health Insurance Exchange, the employer must pay a fee to help cover the cost of tax credits.

enrollment date

The first day of coverage or, if your group has a waiting period prior to coverage, the first day of the waiting period (for example, the date your employment begins).

essential health benefits

Some benefits will be included in every insurance plan. Beginning in 2014, most insurance plans you can choose from – whether you buy on the health insurance exchange or go directly to the insurance company of your choice – will include many benefits that are meant to make sure basic health concerns are covered.

exclusions

Specific medical conditions, procedures or circumstances that are not covered under a health care plan.

Explanation of Benefits (EOB)

The form sent to you after a claim payment has been processed by your health care plan. The EOB explains the actions taken on the claim such as the amount that will be paid, the benefit available, reasons for denying payment and the claims appeal process.


F

family coverage

Health care coverage for a member and his or her eligible dependents.

Federal Poverty Level (FPL)

A level of income issued annually by the Department of Health and Human Services – used to determine eligibility for certain programs and benefits. FPL will be used to determine the amount of tax credit you qualify for to offset the cost of purchasing health insurance.

formulary

A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.


G

generic drug

A prescription drug that is the generic equivalent of a brand-name drug listed on your health plan's drug list (formulary).

generic substitute

A prescription drug which is the generic equivalent of a drug listed on your health plans formulary.

grandfathered health plan

A health plan that was in place when the new health care law was passed into law. A grandfathered plan is exempt from some requirements of the new law.  The grandfather rule enables businesses and families to keep the plan they have, if they wish to. 

group

A group of people covered under the same health care plan and identified by their relation to the same employer.

guaranteed issue

A requirement under the Affordable Care Act that health plans must permit you to enroll in some form of insurance coverage regardless of health status, age, gender or other factors.


H

Health Maintenance Organization (HMO)

An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers.

High Risk Pool Plan (State)

Plans that provide coverage if you have a serious health condition that prevents you from getting private insurance.  The new law established the Pre-existing Condition Insurance Plan. Some states also have their own high risk pool plan. In 2014 when guaranteed issue goes into effect, many states may choose to no longer offer a high risk insurance pool plan.

HIPAA

A federal law which outlines certain rules and requirements employer-sponsored group health plans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups; most recently amended to add privacy rules which became effective April 14, 2003.


I

individual health insurance plan

Health care coverage for an individual with no covered dependents. Also knows as individual coverage.

in-network

Covered services provided or ordered by your primary care physician (PCP) or another provider referred by a your primary care physician.

individual mandate

Starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren’t, you may be required to pay a penalty on your income tax filing. You won't have to pay an assessment if you have very low income and coverage is unaffordable to you, or for other reasons including your religious beliefs. You can also apply for a waiver asking not to pay an assessment if you don't qualify automatically.

inpatient services

Services provided when a member is registered as a bed patient and is treated as such in a hospital or other health care facility.


J


K


L

lifetime limit

A cap on the total lifetime benefits you may get from your insurance company, either on all coverage or for a certain condition.  A health plan may have a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime), or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services. Under the new health care law, lifetime limits are no longer allowed in most cases.


M

Medicaid

A joint federal and state funded program that provides health care coverage for low-income children and families, and for certain aged and disabled individuals.

medical group

A licensed health care facility, program, agency, doctor or health professional that contracts with a health plan to deliver health care services to plan members.

Medicare

The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65.

Medicare Part A

The federal program established to provide health care coverage for eligible senior citizens. Medicare Part A provides basic hospital insurance coverage automatically for most eligible persons.

Medicare Part B

The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part B provides benefits to help cover the costs of doctors' services.

Medicare Part C

The federal program established to provide health care coverage for eligible senior citizens. Medicare Part B provides benefits to cover the costs of doctors' services.

member

Any individual who receives health care coverage from Blue Cross and Blue Shield of New Mexico.


N

network

The group of doctors, hospitals and other medical care professionals that a health care plan has contracted with to deliver medical services to its members.

non-participating provider

A provider (hospital, doctor, or other health care professional or facility) that does not have an agreement with a particular health care plan to provide services to members in that plan.

non-preferred providers

A non-preferred provider does not have a preferred or PPO contract with Blue Cross and Blue Shield of New Mexico. For most benefits, after you've met the non-preferred provider deductible, you will pay a percentage of covered charges for services you receive from non-preferred providers.


O

open enrollment period

The period of time set up to allow you to choose from available health insurance plans, usually once a year. The first open enrollment period for the new health insurance exchange begins in October 2013.

out-of-network

Services not provided or ordered by your primary care physician (PCP) or upon referral of your primary care physician.

out-of-pocket maximum

The maximum amount you have to pay for most or all expenses covered under your health care plan during a defined benefit period.

outpatient

Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.


P

participating hospital

A hospital that has an agreement with a particular health care plan to provide hospital services to members of that plan.

Participating Provider Organization (PPO)

A health care plan that supplies services at a discounted cost for members who use designated health care providers. PPOs usually provide coverage for services rendered by health care providers who are not part of the PPO network, however the member generally shares a greater portion of the cost for such services.

pre-certification

The process by which a plan member or their primary care physician (PCP) notifies the plan, in advance, of plans for the member to undergo a course of care such as a hospital admission or a complex diagnostic test.

participating provider

A provider (hospital, doctor, or other health care professional or facility) that has an agreement with a particular health care plan to provide services to members of that plan.

pre-existing condition

A condition, disability or illness that you have been treated for before applying for new health coverage.

preferred provider

A health care professional or a facility that has a preferred or PPO contract with Blue Cross and Blue Shield of New Mexico or another Blue Cross and Blue Shield Plan.

preferred drug list

A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a health plan's prescription drug list are automatically covered under that plan.

premium

The ongoing amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. The premium may not be the only amount you pay for insurance coverage. Typically, you will also have a co-payment or deductible amount in addition to your premium.

prescription drugs

Drugs and medications that, by law, must be dispensed by a written prescription from a licensed doctor.

prescription drug list

A list of commonly prescribed drugs (also known as a drug formulary). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.

preventive services

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

primary care physician (PCP)

The physician you choose to be your primary source for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Not all health plans require a PCP or referrals.

prior approval

The process by which a plan member or his or her primary care physician (PCP) notifies the plan, in advance, of plans for the member to undergo a course of care, such as a hospital admission or a complex diagnostic test.

provider

A duly licensed hospital, program, doctor or other medical professional or facility authorized to deliver health care services.

prior authorization

The process by which a plan member or his or her primary care physician (PCP) notifies the plan, in advance, of plans for the member to undergo a course of care, such as a hospital admission or a complex diagnostic test.


Q


R

referral

A primary care physician's (PCP) recommendation that a patient see a specific specialist for further treatment. A referral number is assigned and may have a specific number of days, units of treatment, and an expiration date. Not all plans require referrals.


S

specialist

A health care professional whose practice is limited to a certain branch of medicine such as specific procedures, age categories of patients, specific body systems or certain types of diseases.


T


U

urgent care

Situations that are not life threatening (that is, are not medical emergencies), but require prompt medical attention or urgent care. Examples of conditions that are considered urgent are sprains, high fever, and cuts requiring stitches.


V


W


X


Y


Z

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