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Glossary

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Claim:

A request for payment for benefits received or services rendered.

Coinsurance:

The percentage of the allowed amounts for covered services that Blue Cross and Blue Shield of North Carolina (BCBSNC) will pay after a member meets their deductible. For example, if a member selects a plan that covers 80% of the allowable charge for a specific service, BCBSNC will pay 80% of the allowable charges to the provider and the member will be required to pay provider the remaining 20%. The member would pay the 20% until the coinsurance maximum is reached.

Note: Some services and supplies received by members in an office setting or in connection with an office visit are in fact provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Prior to scheduling an appointment, please confirm with your provider whether the practice is hospital-owned or whether any services are hospital-based and may be subject to deductible and coinsurance.

Coinsurance Maximum:

The total amount of coinsurance that a member is obligated to pay for covered services per benefit period. Once the coinsurance maximum is reached, BCBSNC will cover 100% of all covered services for the rest of the benefit period.

Contributions:

Money that the member (or someone else) deposits into a health savings account (HSA). Contributions are tax-deductible subject to annual limitations outlined by the IRS and based on whether the member is enrolled in an Individual HSA or Family HSA Plan.

Co-payment (or copay):

The fixed dollar amount a member pays to their health care provider or pharmacy when covered services are rendered by the health care provider or when the covered prescription drug is purchased.

Note: Some services and supplies received by members in an office setting or in connection with an office visit are in fact provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Prior to scheduling an appointment, please confirm with your provider whether the practice is hospital-owned or whether any services are hospital-based and may be subject to deductible and coinsurance.

Deductible:

The amount a member must pay before BCBSNC will begin paying toward some services. Deductibles are fixed dollar amounts and are tied to a member's annual benefit period. There may be separate deductible amounts for different benefits, such as hospitalization and prescription drug coverage.

Note: Some services and supplies received by members in an office setting or in connection with an office visit are in fact provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Prior to scheduling an appointment, please confirm with your provider whether the practice is hospital-owned or whether any services are hospital-based and may be subject to deductible and coinsurance.

Dependent:

A dependent is a person (spouse of child) other than the subscriber who is covered on the subscriber's policy. Even if a spouse or child is listed on a policy, only the subscriber is allowed to make changes to the policy.

Distribution:

Money that a member withdraws from their health savings account (HSA). Withdrawals can be made in a variety of ways, including an HSA debit card or checkbook.

High-Deductible Health Plan (HDHP):

A federally-defined health benefit design that qualifies a member to open a health savings account (HSA). Members covered under high deductible health plans do not have benefits for any coverage (e.g., office visits, emergency room visits and prescription drugs) prior to meeting the deductible (with the exception of preventive care).

Health Savings Account (HSA):

An investment or retirement account from which a member can withdraw money tax-free to pay for qualified medical expenses. An HSA is used with an HSA-compatible health insurance plan. Dollars that are not used in a given year roll over to the next year and are completely portable should a member change jobs or switch health coverage.

Health Coverage Tax Credit (HCTC):

A tax credit provided by the government to help displaced workers pay for health insurance. For questions regarding HCTC eligibility, please call the HCTC Center toll-free number 1-866-628-4282.

In-network:

Refers to the use of providers who participate in a health plan's provider network. Many benefit plans encourage members to use participating (in-network) providers to reduce out-of-pocket expenses.

Out-of-network:

Refers to the use of providers who do not participate in a health plan's provider network. Out-of-network providers are those who have not signed a contract with BCBSNC to be part of the provider network. Covered services obtained from an out-of-network provider usually result in higher out-of-pocket.

PPO:

Stands for Preferred Provider Organization. This type of health insurance plan offers both in- and out-of-network coverage. However, out-of-network visits usually require higher out-of-pocket costs. No referrals are required in order to access care in a PPO plan.

Preventive care:

Medical services provided by or upon the direction of a doctor or other provider related to the prevention of disease. For covered members, these services include: routine physical exams, gynecological exams, mammography screenings, standard immunizations, well-baby and well-child care and screenings for cervical and prostate cancer.

Primary Care Physician (PCP):

A doctor selected by a member to be the first physician contacted for any medical problem. A primary care physician acts as a patient's regular physician and coordinates any other care a patient needs, such as a specialist visit or hospitalization. Primary care physicians typically include family practice, general practice and internal medicine doctors.

Specialists:

Providers whose practices are limited to treating specific diseases (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), or specific procedures (e.g., oral surgery).

Subscriber:

The person whose name appears on the ID card issued by BCBSNC and who is enrolled according to BCBSNC records. In the context of a group insurance plan, the subscriber is the individual who belongs to the group (e.g., employee).

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