Common health insurance terms

A US health care law started in 2010 to help people get access to health insurance, improve health care quality, and reduce health care costs. The ACA includes subsidies for low-income groups, Medicaid expansion, and regulations on insurance companies. You can find more information about the ACA on Healthcare.gov⁠.

For members: the maximum amount that Blue Cross and Blue Shield of North Carolina (Blue Cross NC) determines is reasonable for covered services provided to a member. The allowed amount includes any Blue Cross NC payment to the provider, plus any deductible, coinsurance, or copayment.

For providers: that have entered into an agreement with Blue Cross NC, the allowed amount is the negotiated amount that the provider has agreed to accept as payment in full. The allowed amount may be based on a schedule of fees, capitated arrangement, or other formula agreed upon between the provider and Blue Cross NC.

The yearly period of time from November to January when people age 65 and older can enroll in or make changes to their Medicare health insurance coverage. Making changes outside of this period generally requires a qualifying life event or special enrollment period.

A request to review a denied claim. You or your provider can submit an appeal to your health insurance company. The appeal process typically involves sending additional documents to prove why you and your doctor want coverage approved.

The services and treatments covered by a health insurance plan. Benefits typically include medical services, such as doctor visits, hospital stays, prescription drugs, and preventive care.

The period of time, as stated in the “Summary of Benefits” and group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by Blue Cross NC. A charge shall be considered incurred on the date the service or supply was provided to a member.

The maximum dollar amount for covered services or number of visits in a benefit period that will be covered on behalf of a member. Services in excess of a benefit period maximum are not covered services, and members may be responsible for the entire amount of the provider’s billed charge.

The proprietary name of the prescription drug that the manufacturer owning the patent places upon a drug product or on its container, label, or wrapping at the time of packaging. A brand-name drug has a trade name and is protected by a patent and can only be produced and sold by the manufacturer owning the patent.

Blue Cross NC makes the final determination of the classification of brand-name drug products based on information provided by the manufacturer and other external classification sources, such as the US Food and Drug Administration (FDA) and nationally-recognized drug databases.

A formal request submitted to your insurance company for payment of medical services performed by your provider. Once approved, the insurance company pays the provider for covered expenses. Learn more about how to submit a claim.

COBRA allows eligible employees and their dependents to continue their group health insurance coverage for a limited time after experiencing a qualifying event, such as job loss or reduced hours. By choosing to use COBRA, you are typically required to pay the full health insurance premium, including the portion previously covered by your employer.

The sharing of charges by Blue Cross NC and you for covered services, after you have met your benefit period deductible. This is stated as a percentage. The coinsurance listed is your share of the cost of a covered service.

The fixed dollar amount you must pay for some covered services at the time you receive them, if this health benefit plan includes copayments. Copayments are not credited to the deductible; however, they are credited to the total out-of-pocket limit.

The financial responsibility you have for health care expenses covered by your insurance plans. It includes various out-of-pocket costs, including deductibles, copayments, and coinsurance.

The medical services and treatments that the insurance plan will pay for, either fully or partially.

A service, drug, supply, or equipment specified in the Benefit Booklet for which members are entitled to benefits in accordance with the terms and conditions of this health benefit plan. Any services in excess of a benefit period maximum or lifetime maximum are not covered services.

The amount of money you must pay for covered services in a benefit period before Blue Cross NC begins to pay for covered services. The deductible does not include coinsurance, charges in excess of the allowed amount, amounts exceeding any maximum, or charges for noncovered services.

A member other than the subscriber as specified in “When Coverage Begins and Ends" of the member's Benefit Booklet.

Health care items and services furnished or required to screen for or treat an emergency medical condition, including but not limited to, pre-hospital care, and ancillary services routinely available in the emergency department.

Treatments or procedures that are not covered (excluded) by the insurance plan.

An EOB is a document that explains the costs for provided health care services and how the insurance plan covered those costs. In an EOB, you will find details about the dates of services, billed amounts, what your insurance plan covered, and any unpaid costs you may owe, including copayments or deductibles.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) members can choose to get their EOBs by mail or sent to their member portal.

An FSA is a pre-tax savings account. Pre-tax means you don't pay taxes on this money. Often, FSAs may be part of an employer's health plan offerings.

A plan with an FSA gives employees the option to set aside money for eligible medical expenses, including copayments, deductibles, and certain over-the-counter medications. Money in your FSA must be used during your coverage year because leftover money will not rollover to the next year.

The list of outpatient prescription drugs, insulin, and certain over-the-counter drugs that may be available to members. Learn more about prescription drug costs.

A prescription drug that has the same active ingredient as a brand-name drug, has the same dosage form, and strength as the brand-name drug, and has the same mechanism of action in the body as the brand-name drug.

The classification of a prescription drug as a generic is determined by Blue Cross NC based on commercially available data resources and other external classification sources, such as the US Food and Drug Administration (FDA) and nationally-recognized drug databases.

An HRA is a benefit plan funded by an employer that pays employees back for qualified medical expenses not covered by their health insurance, such as deductibles, copayments, and certain out-of-pocket costs.

Often available to individuals with high-deductible health plans an HSA allows you to save money for qualified medical expenses, such as deductibles, copayments, and coinsurance. The money added to your HSA is pre-tax (meaning you don't pay taxes on it) and HSA money doesn't go away each year. That means you can use your HSA money on eligible medical expenses anytime you need it.

A health insurance plan with a higher deductible amount and a lower monthly premium or bill.

The Health Insurance Marketplace, also known as the Exchange, was established by the ACA. The Marketplace is a platform where individuals and small businesses can compare and purchase different health insurance plans.

HIPAA establishes privacy and security standards to protect patients' medical information. It also includes provisions to facilitate the electronic exchange of health information and mandates penalties for violations of patient privacy and security regulations.

A type of managed health care insurance plan that typically requires you to choose a primary care provider (PCP) and to get referrals from your PCP for specialist care.

A hospital, doctor, other medical practitioner, or provider of medical services and supplies that has been designated as an in-network provider by Blue Cross NC or a provider participating in the BlueCard^® Program.

Ancillary providers outside North Carolina are considered in-network only if they contract directly with the Blue Cross or Blue Shield plan in the state where services are received, even if they participate in the BlueCard program.

The period during which someone can initially enroll in a health insurance plan when they become eligible for coverage, such as when they turn 65 for Medicare.

A joint federal and state program that provides health insurance coverage to low-income people and families, including children, pregnant women, elderly individuals, and people with disabilities.

Those covered services or supplies that are:

1. Provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease; and, except for clinical trials as described under this health benefit plan, not for experimental, investigational, or cosmetic purposes,
2. Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms,
3. Within generally accepted standards of medical care in the community, and
4. Not solely for the convenience of the insured, the insured’s family, or the provider.

For medically necessary services, Blue Cross NC may compare the cost-effectiveness of alternative services, settings or supplies when determining which of the services or supplies will be covered and in what setting medically necessary services are eligible for coverage.

A federal health insurance program primarily for people aged 65 and older. Medicare has different parts, including Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage).

A subscriber or dependent, who is currently enrolled in this health benefit plan and for whom premium is paid.

The group of health care providers, facilities, and pharmacies that have contracted with a specific health insurance plan to provide services to insured people at negotiated rates.

Prescription medications that are not included on the list of covered drugs of a particular health insurance plan. Learn more about non-formulary drugs.

A specified period during which someone who is 64 years old and younger can enroll in or make changes to their health insurance coverage without needing a qualifying life event.

Not designated as participating in the plan’s network of covered providers and not certified in advance by Blue Cross NC to be considered as in-network. Our payment for out-of-network covered services is described in the Benefit Booklet as out-of-network benefits or out-of-network benefit levels.

A provider that has not been designated as an in-network provider by Blue Cross NC.

The maximum amount of coinsurance that is payable by the member in a benefit period before Blue Cross NC pays 100% of covered services. It does not include deductible, or any applicable copayments.

A type of health insurance plan that offers more flexibility in choosing health care providers compared to HMOs. The insured person can typically receive care from both in-network and out-of-network providers, but they generally pay lower out-of-pocket costs when they use in-network providers.

The amount of money that you and / or your employer pays to the insurance company to maintain health insurance coverage.

Medical services provided by or upon the direction of a doctor or other provider that detect disease early in patients who do not show any signs or symptoms of a disease.

Preventive care services include immunizations, medications that delay or prevent a disease, and screening and counseling services. Screening services are specific procedures and tests that identify disease and/or risk factors before the beginning of any signs and symptoms. Learn more about preventive care.

A drug that has been approved by the US Food and Drug Administration (FDA) and is required, prior to being dispensed or delivered, to be labeled “Caution: Federal law prohibits dispensing without prescription,” or labeled in a similar manner, and is appropriate to be administered without the presence of a medical supervisor.

An in-network provider who has been designated by Blue Cross NC as a primary care provider (PCP).

The consideration of benefits for an admission, availability of care, continued stay, or other services, supplies or drugs, based on the information provided and requirements for a determination of medical necessity of services and supplies, appropriateness, health care setting, or level of care and effectiveness.

Prior review results in certification or noncertification of benefits. Learn more about prior authorization.

Any information that can be used to identify a patient and relates to the person's past, present, or future physical or mental health condition, health care services, or payment for health care services.

A hospital, nonhospital facility, doctor, or other provider, accredited, licensed, or certified where required in the state of practice, performing within the scope of license or certification. All services performed must be within the scope of license or certification to be eligible for reimbursement.

Events that may cause special enrollment periods (SEPs). During an SEP, you can enroll in or make changes to your health insurance coverage outside of the annual open enrollment period.

Qualifying life events may include marriage, divorce, birth or adoption of a child, loss of other health coverage, or a change in residence.

A recommendation from a primary care provider (PCP) to see a specialist or receive certain medical services.

A nonhospital facility licensed under state law that provides skilled nursing, rehabilitative, and related care where professional medical services are administered by a registered or licensed practical nurse. All services performed must be within the scope of license or certification to be eligible for reimbursement.

A doctor who is recognized by Blue Cross NC as specializing in an area of medical practice.

Those medications classified by Blue Cross NC that generally have unique indications or uses, or require special dosing or administration, or are typically prescribed by a specialist, or are significantly more expensive than alternative therapies. Specialty drugs may be self-administered or provider-administered and classified as generic, brand-name, biologic, or biosimilar.

A designated period during which someone can enroll in or make changes to their health insurance coverage outside of the open enrollment period, typically after going through a qualifying life event. Learn more about special enrollment periods.

Covered prescription drugs or devices for which reimbursement by Blue Cross NC is conditioned on: (1) Blue Cross NC’s giving certification to prescribe the drug or device or (2) the provider prescribing one or more alternative drugs or devices before prescribing the drug or device in question.

The person who is eligible for coverage under this health benefit plan due to employment and who is enrolled for coverage.

The use of video appointments or phone calls to provide virtual health care services to patients outside of a doctor's office or care facility.

The maximum amount listed in “Summary of Benefits” that is payable by the member in a benefit period before Blue Cross NC pays 100% of covered services.  It consists of the out-of-pocket expense (which is the annual maximum amount of coinsurance and any copayments) plus the deductible.

Services provided for a condition that occurs suddenly and unexpectedly, requiring prompt diagnosis or treatment, such that in the absence of immediate care the individual could reasonably be expected to suffer chronic illness, prolonged impairment, or require a more hazardous treatment. Fever over 101 degrees Fahrenheit, ear infection, sprains, some lacerations, and dizziness are examples of conditions that would be considered urgent.

A set of formal processes that are used to evaluate the medical necessity, quality of care, cost-effectiveness, and appropriateness of many health care services, including procedures, treatments, medical devices, providers, and facilities.

The amount of time that must pass before a member is eligible to be covered for benefits under the terms of this health benefit plan.