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Glossary

ACA – Affordable Care Act- The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

Allowed Amount – The charge that BCBSNC determines is reasonable for a covered service.  This amount may be determined by agreement between the provider and BCBSNC.  BCBSNC does not pay benefits on amounts that exceed the allowed amount.  If you use an out-of-network provider who charges more than the allowed amount, you are responsible for coinsurance plus 100% of that charge that exceeds the allowed amount.

Blue Options Provider- A participating provider who agrees to charge specified rates for care.

Coinsurance – The percentage of the cost you pay for certain services once you meet your deductible.  For example, under the Traditional 70/30 Plan, a member pays 30% coinsurance for an MRI performed through a network provider.  If the bill comes in at $100, the member pays $30 (30% of $100).  Under the Enhanced 80/20 Plan, a member pays 20% coinsurance for that same service.  If the bill comes in at $100, the member pays $20 (20% of $100). 

Coinsurance Maximum – Under the Traditional 70/30 and Enhanced 80/20 Plans, this is the most you pay for coinsurance in a calendar year.  It excludes premiums, deductibles and copays.  For the limit under the CDHP, see out-of-pocket maximum. 

Consumer-Directed Health Plan (CDHP)- A new health plan option that includes a high deductible health plan, a Health Reimbursement Account (HRA) and incentives to encourage decisions that are good for your health.

Deductible – The amount you pay each year before a plan pays benefits for services that require coinsurance.  Under the Traditional 70/30 and Enhanced 80/20 Plans, the deductible does not apply to services with a copay except for inpatient hospital.  All plans have in-network and out-of-network deductibles.  Payments for out-of-network services count toward the in-network deductible, but payments for in-network services do not count toward the out-of-network deductible.  All plans also have an individual and family deductible.  If the family deductible is satisfied, all individual deductibles are also satisfied. 

Explanation of Benefits (EOB)- An EOB often looks like a medical bill, but actually gives you details regarding how your insurance company processed medical insurance claims. The EOB tells you what portion of a claim was paid to the health care provider and what portion of the payment, if any, you are responsible for.

Health Assessment – A confidential questionnaire about your health and lifestyle that helps identify potential health risks. 

Health Reimbursement Account (HRA) – Under the CDHP, an account established for you by the Plan to help you meet your annual deductible. 

Out of Pocket Maximum – Under the CDHP, this is the most you pay for covered expenses (medical and pharmacy) in a calendar year.  It includes deductibles and coinsurance but excludes premiums.  For the limit under the Traditional 70/30 and Enhanced 80/20 Plans, see coinsurance maximum. 

Personal Health Portal- An online resource that allows you to find information, prevention tips, lifestyle changes and healthy living tips and the tools to make the information work for your life.

Preventive Medications (ACA) – A list of preventive medications required by the Affordable Care Act to be covered at 100% with no member cost share.  The list of medications is based on recommendations from the US Preventive Services Task Force.  The government guidelines are updated periodically and are subject to change.

Preventive Medications (CDHP) – A list of preventive medications used to help prevent, treat and manage certain health conditions.  The prescription medications on this list will be covered as if the deductible is already met and will be subject only to coinsurance.  This list is subject to change.

Preventive Services- They are provided to help you avoid becoming sick in the first place. Mammograms, flu shots, Pap tests and pelvic exams are examples of preventive services.

Primary Care Physician (PCP) – A medical professional (a doctor who practices general medicine, internal medicine, pediatrics or obstetrics and gynecology or a licensed family nurse practitioner or physician’s assistant) whom you select to oversee all of your health care.  Your PCP is listed on your member ID card, but choosing a PCP does not limit you to that provider in any way. 

Wellness Incentives – Financial rewards available under the Enhanced 80/20 Plan and CDHP for using your PCP and Blue Options Designated providers.

Wellness Premium Credits – Reductions in your premium available under the Enhanced 80/20 Plan and CDHP for attesting that you don’t smoke (or signing up for a smoking-cessation program by January 1, 2014), completing a Health Assessment and selecting a PCP.