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.

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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.

For cause

Includes, but is not limited to, any of the following: (1) breach of contract; (2) a civil case ruling, settlement in a civil or criminal matter, a verdict or plea of guilty or a plea of nolo contendere, and/or any other instance determined by BCBSKS as moral turpitude; and/or (3) any act of defamation, slander, and libel toward BCBSKS and its subsidiaries (as determined by BCBSKS).

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.

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.

Habilitation services

Healthcare 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 healthcare 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 profile

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

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 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 healthcare

Healthcare 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.

Hospital outpatient care

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

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.

Identification card

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

In-network co-insurance

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

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.

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.

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.

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 healthcare 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 healthplan 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.

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 healthcare 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.

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 healthcare 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 copayment

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

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 healthcare 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.

Participant agreement

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

Physician services

Healthcare 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 healthcare 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 Blvd., Topeka, KS, 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.

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.