Glossary

As you explore our site, you may come across an unfamiliar word or term. We've developed a glossary that we hope will help you.

Select the first letter of the term you're looking for to find the definition.

A B C D E F G H I L M N O P Q R S T W

A

Actual charge – The amount a health care provider actually bills a patient. You may have seen the phrase, "The actual charge may be different from the allowable charge." This means BCBSKS may only cover a portion of what a doctor charges a member. For example, a doctor bills $40 for an office visit. This is the actual charge. But BCBSKS may only allow $35 for an office visit. This is the allowable charge.

Administrative Services Only (ASO) group – Group that contracts with BCBSKS to provide administrative and claims payment services according to the group's coverage criteria. The group assumes the risk for the cost of services the subscribers receive, rather than paying premiums. The group can also purchase stop-loss insurance from BCBSKS that limits such risk.

Allowable charge – The maximum amount BCBSKS will pay for a covered service. You may have seen the phrase, "The actual charge may be different from the allowable charge." This means BCBSKS may only cover a portion of what a doctor charges a member. For example, a doctor bills $40 for an office visit. This is the actual charge. But BCBSKS may only allow $35 for an office visit. This is the allowable charge.

Allowed Amount –Maximum amount on which payment is based for covered health care services. This may be called "eligible expense," "payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.

Ambulatory care – Care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.

Anniversary date – The anniversary of when the coverage was effective.

Anniversary year – The 12-month period based on the group anniversary month.

Appeal – A request for your health insurer or plan to review a decision or grievance again.

Assignment of benefits – When a covered person authorizes his or her health benefits plan to directly pay a health care provider for covered services. Traditional health insurance pays benefits directly to the covered person.

Automatic payment plan (bank draft) – A method of payment where the insurance premium is deducted directly from an account at a financial institution on a monthly basis.

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B

Balance Billing – When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Benefit – Services and supplies a health plan pays for. The term also refers to the amount a health plan allows.

Benefit description – Document that explains the benefits for self-funded (ASO) group subscribers. This is not the same as a Summary Plan Description (SPD) or a Plan Document

Benefit period – The period of time a health plan will pay for covered benefits. Benefit periods are usually one year. They don't always reflect a calendar year.

BlueCard – A teleprocessing system that allows any Blue Cross and Blue Shield Plan to make available to other Blue Cross and Blue Shield Plans (in-or out -of-state) the same discounts they have negotiated with providers for their own customers.

Brand-name drug – A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.

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C

Calendar year – The period between Jan. 1 and Dec. 31 of any given year.

CAP (Competitive Allowance Program) – The reimbursement agreement between BCBSKS and providers of health care services for traditional benefit programs. Providers are paid predetermined maximum allowances for covered health care services and agree to file claims on behalf of members.

Carrier – A company that signs a contract with the federal government to handle Medicare claims from health care providers.

Case management – Coordination of services to help meet a patient's health care needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.

Certificate (also called Certificate of Coverage) – Document describing the benefits included within an insured Group Contract which is issued to each Primary Member. This is not the same as a Summary Plan Description (SPD) or a Plan Document.

Co-insurance – Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Company service area – The geographical area covered by a network of health care providers. BCBSKS covers the state of Kansas, excluding Johnson and Wyandotte counties.

Complications of Pregnancy – Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother and fetus. Morning sickness and a non-emergency caesarean section aren't complications of pregnancy.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – A federal statute that requires most employers (those groups with more than 20 employees) to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time (usually 18 months for employees and dependents who would otherwise lose coverage due to loss of employment or work hour reduction, or 36 months for dependents who would lose coverage for certain reasons other than employment loss by the employee).

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Continued Group Coverage – Employers who offer a group health plan for their employees and have fewer than 20 employees on the payroll are affected by the provisions of the 1984 Kansas Senate Bill 704. This law governs group health insurance benefits for hospital/medical/surgical services. If employees and/or dependents have been covered by group health insurance coverage for 90 days prior to termination, Blue Cross and Blue Shield of Kansas must make available, to the individual(s) affected, the same group hospital/medical/surgical coverage they had prior to termination. This continuation of coverage must be offered at the same premium available through the group for a period of six months. Individuals choosing this option will be billed directly by Blue Cross and Blue Shield of Kansas - not through the group. This law affects all groups except those on self-insurance. If the group health insurance is replaced by a similar group coverage within 31 days, the employee is not eligible for continued group benefits under State continuation and conversion laws. If the employee and/or dependents have not been covered by your group health insurance for 90 days prior to termination, we will automatically offer them our Non-Group Conversion program in lieu of the continuation rights.

Contract year – A period of 12 months, starting the first day of a given month.

Contracting provider – Any licensed provider of health care services who has signed an agreement to accept the BCBSKS allowance as payment-in-full for covered services. Types of contracting providers include (but are not limited to) hospitals, medical care facilities, pharmacies, ambulatory surgical centers, doctors, other licensed or certified practitioners (as described in the contract) and providers of ambulance services.

Co-payment – A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Cost containment – Strategies used to limit or control health care costs that do not sacrifice the quality of care.

Cost sharing – A method of dividing the cost of health care among consumers, insurance companies, employers and providers. For example, an employer may pay part of the premiums for insurance. BCBSKS will pay part of the health care bills, and the member will pay part. If a doctor is part of our network, then he or she will cover part of the cost by negotiating a discount for his or her services. Everyone shares in the expenses to keep costs down.

Covered service – Specific services the health plan will provide benefits for.

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D

Deductible – The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won't pay anything until you've met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Dependent – A person eligible for coverage under a benefits plan because of that person's relationship to the primary member. Spouses and children are often eligible for dependent coverage.

Direct-enrolled – A non-group member who pays his or her insurance premium directly to BCBSKS.

Discharge planning – Identifying a patient's health care needs after discharge from inpatient care.

Disease management – Voluntary programs which give members the information and support needed to live well with chronic conditions. These programs help members understand their doctors' instructions and improve the way they care for themselves every day.

Disenrollment – Voluntarily terminating one's participation in a health benefits plan.

Duplication of benefits – This provision applies to covered group employees (or family members of the employee) who are eligible for benefits from another group health care plan. Duplication of benefits coordination is conducted to make sure members do not profit by receiving payment from more than one source.

Durable Medical Equipment (DME) – Equipment and supplies ordered by a health provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

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E

Eligible – Provisions contained in each health benefits plan that specify who qualifies for coverage under that plan.

Emergency Medical Condition – An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Medical Transportation – Ambulance services for an emergency medical condition.

Emergency Room Care – Emergency services you get in an emergency room.

Emergency Services – Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Employee Retirement Income Security Act of 1974 (ERISA) – Federal legislation that establishes certain rights and protections to participants of most employer welfare (e.g., health, dental, life) and pension (e.g., 401(k), retirement) benefit plans.

Excluded Services – Health care services that your health insurance or plan doesn't pay for or cover.

Explanation of Benefits (EOB) - A summary sent to the member showing how much BCBSKS paid, what the member's financial responsibility may be, and any provider write-offs.

Explanation of Medicare Benefits – See Medicare Summary Notice.

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F

Fee for Service – This is indemnity insurance. Doctors and hospitals are paid for each service they perform/provide. (See Traditional)

Flexible Spending Accounts –Employer-established benefit plans that reimburse employees for specified medical expenses as they are incurred. These accounts are allowed under section 125 of the Internal Revenue Code and are also referred to as "cafeteria plans" or "125 plans." The employee contributes funds to the account through a salary reduction agreement and is able to withdraw the funds set aside to pay for medical bills. The salary reduction agreement means that any funds set aside in a flexible spending account escape both income tax and Social Security tax. Employers may contribute to these accounts as well. By law, the employee forfeits any unspent funds in the account at the end of the year.

Formulary – A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost.

Fraud – A deception that could result in BCBSKS paying for something it shouldn't. For example, if a provider files a claim for a service that wasn't received, this is fraud.

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G

Generic drug – A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs and are typically less costly.

Grievance – A complaint that you communicate to your health insurer or plan.

Group – The business organization or legal entity which has entered into the contract with BCBSKS, for the provision of medical and hospital services.

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H

Habilitation Services – Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance – A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Health maintenance organization (HMO) – A form of health insurance in which its members prepay a premium for health services, which generally includes inpatient and ambulatory care. HMOs can be both insurers and providers of care.

Health reimbursement arrangements – A type of health insurance plan that reimburses employees for qualified medical expenses. These accounts consist of funds set aside by employers to reimburse employees for qualified medical expenses, just as an insurance plan will reimburse covered individuals for the cost of services incurred. HRAs provide "first-dollar" medical coverage until funds are exhausted. For example, if an employee has a $500 qualifying medical expense, then the full amount will be covered by the health reimbursement arrangement if the funds are available in the account. Under a health reimbursement account, the employer provides funds, not the employee. All unused funds are rolled over at the end of the year. Former employees, including retirees, can have continued access to unused reimbursement amounts. Health reimbursement accounts remain with the originating employer and do not follow an employee to new employment.

Health profile – A form when completed by the applicant that offers health history information and is used to determine the premium and establish coverage.

Health savings accounts – An option for health insurance that has two parts. The first part is a qualifying high-deductible health plan. The second part of the Health Savings Account is an investment account or retirement account from which you can withdraw money tax-free for medical care. Otherwise, the money accumulates with tax-free interest until retirement, when you can withdraw for any purpose and pay normal income taxes.

Home Health Care – Health care services a person receives at home.

Hospice Services – Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization – Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care – Care in a hospital that usually doesn't require an overnight stay.

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I

Identification card – The card issued to identify a member of BCBSKS and what coverage the member and any family members on the policy have.

Indemnity plan – A type of health benefits plan under which the covered person pays 100 percent of all covered charges up to an annual deductible. The health benefits plan then pays a percentage of covered charges up to an out-of-pocket maximum.

In-network Co-insurance – The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

In-network Co-payment – A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.

Inpatient – A patient who is staying in the hospital and receiving room, board and general nursing care.

Insured – Person who is eligible, enrolled and covered by an insurance contract. This term is used in contracts and certificates for underwritten business.

Intermediary – A company that signs a contract with the federal government to handle Medicare payments for hospital, skilled nursing facility and home health agency services.

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L

Late enrollee – An employee who did not enroll at the first opportunity or following a qualifying event must wait until open enrollment to enroll. Open enrollment is defined as the month preceding the employer group health plan anniversary date. The request for application must be completed and received by Blue Cross and Blue Shield of Kansas in the month preceding the employer group health plan anniversary date.

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M

Managed care – A prepaid health plan or insurance program in which members coordinate their care through a primary care physician (PCP). The primary goal is to deliver cost-effective health care without sacrificing quality or access.

Medically Necessary – Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Medicare Summary Notice (MSN) – A summary sent to the member showing how much Medicare paid, what the member's financial responsibility may be, and any provider write-offs.

Medicare supplement policy – A health plan for people with Medicare coverage, also known as a Medigap plan. Medicare doesn't cover everything, so many people buy a Medicare supplement policy to help cover their health care bills. There are 12 standardized plans to choose from. This means that all companies can only offer the same policies, "A" through "L." "A" is the most basic plan, while "L" covers more services. BCBSKS offers Plans A, C, F and K.

Member – A term used in all BCBSKS internal and external communications to broadly define any person who is enrolled with benefits. For purposes of internal and external communications, a member may include an insured, a policyholder, a subscriber, or a dependent. A member must be a policyholder to vote in person or by proxy at BCBSKS policyholder meetings.

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N

Name brand drug –A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.

Network –The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

No-fault motor vehicle coverage – Coverage that pays for losses associated with a motor vehicle accident regardless of the fault of the driver.

Non-contracting provider – An eligible provider who has not entered into a Contracting Provider Agreement with BCBSKS. Payment for covered services is sent directly to the member and cannot be signed over to the provider. The member is responsible for amounts in excess of the maximum payment allowance. The non-contracting provider is responsible for collecting payment from the member. (Payment can be sent directly to an out-of-state provider.)

Non-Preferred Provider – A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers.

Notice of enrollment rights – Should an employee decline enrollment in a group health plan at his or her first opportunity, an employer would provide to the employee a notice of enrollment rights. This notice advises the employee of what to expect should he or she wish to enroll at a later date.

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O

Open access plan – A health plan that lets a member visit any doctor in the plan's network. A referral isn't needed from a primary care physician.

Open enrollment – A period during which individuals not previously enrolled in the health insurance plan are allowed to apply for coverage or change their coverage status.

Out-of-network Co-insurance – The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.

Out-of-network Co-payment – A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.

Out-of-pocket limit – The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn't cover. Some health insurance or plans don't count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

Outpatient – A patient who gets treatment at a hospital but doesn't stay there. For example, a member goes to the hospital in the morning for minor surgery. After waking up from the anesthesia, the doctor sends the patient home to recover.

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P


Participant Agreement – ASO Benefit description, non-group contract, insured group certificate or other coverage document that links the Primary Member to benefits.

Physician Services – Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

Plan – A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

Point-of-Service (POS) – A prepaid health plan or insurance program that offers the convenience and comprehensive coverage of a managed benefits program by working with a primary care physician for maximum benefits, but also allowing a member to self-refer at a lower payment level of benefits as with the flexibility of a traditional benefits program. Sometimes referred to as self-referred option (SRO).

Policyholder – The person or entity to which the insurance contract has been issued is a member of BCBSKS and is entitled to vote in person or by proxy at meetings of policyholders.

Policyholder Meeting – An annual meeting of policyholders held on the second Thursday in May of each year at 8:30 a.m. at the corporation’s principal place of business at 1133 SW Topeka Boulevard, Topeka, Kansas, or at such other place as the Chairman of the Board of Directors might designate in a notice of meeting given to policyholders. Printed notice shall be sufficient notification.

Preauthorization – A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, expect in an emergency. Preauthorization isn't a promise your health insurance or plan will cover the cost.

Pre-certification – The process of deciding whether or not BCBSKS will cover a specific service. Check the health plan carefully. Certain procedures, like surgery, require pre-certification. This means the member needs to check with BCBSKS to see if the service is covered before it is received.

Pre-existing condition – An injury or illness that is evident before the effective date of the contract. Many health plans do not cover pre-existing conditions. Or, they have a waiting period before the member can receive benefits for them. For example, you hurt your knee playing football a couple years ago and had to have surgery. When you sign up for a new health plan, you'll have to list your knee injury as a pre-existing condition.

Preferred Provider – A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also "participating" providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Preferred Provider Organization (PPO) plan – A network-based, managed care plan that allows the participant to choose any health care provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverages and lower deductibles.

Premium – The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Prescription Drug Coverage – Health insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs – Drugs and medications that by law require a prescription.

Preventive care – Medical and dental services aimed at early detection and intervention.

Primary Care Physician – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Provider – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Primary Member – The person identified on the ASO benefit description, non-group contract, insured group certificate or other coverage document.

Provider – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

Provider discounts – The amount of money contracting health care providers deduct from their charge due to contracts between themselves and a health plan.

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Q

Qualifying event – An event such as death, divorce or spouse's loss of employment that would allow enrollment in another health plan without having to wait for an open enrollment period.

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R

Reconstructive Surgery – Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

Referral – If a primary care physician (PCP) determines a patient has a condition which requires the attention of a specialist, the PCP makes coordinates the transfer of care to a specialist.

Rehabilitation Services – Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

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S

Skilled Nursing Care – Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialist – A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

Status change – A lifestyle event that may cause a person to modify their health benefits coverage category. Examples include, but are not limited to, the birth of a child, divorce or marriage. See Qualifying Event.

Subscriber – Person who is eligible, enrolled and covered under a self-funded ASO (Administrative Services Only) group benefit plan.

Summary of Claims Processed (SOCP) – See Explanation of Benefits.

Summary Plan Description – An ERISA-required summary of plan eligibility, benefits and other information provided by employer groups to anyone participating in an ERISA plan.

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T

Traditional – A pre-paid fee-for-service health plan that gives members maximum freedom of choice, allowing them to seek medical care from any health care provider without reduction of benefits.

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U

UCR (Usual, Customary and Reasonable) – The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care – Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

W

Waiting period – A period of time the member must wait before coverage begins. Two common types of waiting periods are company-imposed and for pre-existing conditions.

Workers' compensation – Insurance purchased by the employer to provide benefits to employees for illness or injury that arises out of or in the course of employment without regard to negligence or fault.

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