Glossary of health insurance terms

Behavioral health is a general term that encompasses the promotion of emotional health; the prevention of mental illnesses and substance use disorders; and treatments and services for mental and/or substance use disorders.

Limits people set in order to create a healthy sense of personal space. Boundaries can be physical or emotional in nature, and they help distinguish the desires, needs, and preferences of one person from another.

The percentage of costs of a covered healthcare service you pay (for example, 20%) after you’ve paid your deductible.

The fixed amount (for example, $25) you pay for a covered healthcare service, usually when you receive the service. The amount can vary, depending on the provider and the type of healthcare service.

The amount you pay for services received before your health plan begins to pay. For example, if your deductible is $1,000, your health plan will not pay for covered services until you’ve paid $1,000 toward your covered healthcare expenses. Once your deductible is met, your health plan will begin to pay a portion of your covered healthcare.

A negative affective state – ranging from unhappiness and discontent to an extreme feeling of sadness, pessimism, and despondency – that interferes with daily life. Depressed individuals may experience altered eating or sleeping habits, lack of energy or motivation, difficulty concentrating or making decisions, and withdrawal from social activities.

A pattern of behavior in which one person deliberately and repeatedly subjects another to nonphysical acts that are detrimental to behavioral and affective functioning and overall mental well-being. It may include verbal abuse; intimidation and terrorization; humiliation and degradation; exploitation; harassment; rejection and withholding of affection; isolation; and excessive control.

Understanding a person from their frame of reference rather than one’s own, or vicariously experiencing that person’s feelings, perceptions, and thoughts.

A type of health plan where you receive healthcare services only from doctors, hospitals and specialists in your plan’s network. There is no out-of-network coverage except for emergency services. Non-emergency services received out-of-network are not covered.

It looks like a bill, feels like a bill, but an EOB is not a bill. If you have a health plan, it’s the statement you get from your insurance company after you receive services from a healthcare provider. The EOB lists several things including the services you received, the amount of cost your plan covers and the total amount billed to you.

The mindset that views intelligence, abilities, and talents as inherently stable and unchangeable over time.

The anguish experienced after significant loss, usually the death of a beloved person. Grief often includes physiological distress, separation anxiety, confusion, yearning, obsessive dwelling on the past, and apprehension about the future. Grief may also take the form of regret for something lost, remorse for something done, or sorrow for a mishap to oneself.

The mindset that views intelligence, abilities, and talents as learnable and capable of improvement through effort.

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integral care and focus on prevention and wellness.

A service for the prevention, diagnosis and or treatment of a health condition.

A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more healthcare costs yourself (your deductible) before the insurance company starts to pay its share. Certain plans that meet IRS guidelines are called Qualified High Deductible Health Plans (QHDHP). QHDHP plans can be combined with a Health Savings Account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes.

A certified agency that provides healthcare services in a member’s home.

An organization that provides medical services such as a chaplain and on call nurse and medical supplies to individuals who are terminally ill.

A facility that provides 24 hour healthcare and nursing services to treat injured and sick patients on an inpatient and outpatient basis.

A hospital, pharmacy, physician or other medical service provider that has a contract to participate in one or more plans with Blue KC. A provider who is considered in-network for one plan may be considered out-of-network for another plan.

An out-of-network provider is any provider that does not have a contract with your healthcare plan. Generally, your insurance company will pay less money or not pay anything at all for services you receive from out-of-network providers. To save money, it’s important to understand who is an in-network provider in your healthcare plan. To learn more, access the Find Care tool on BlueKC.com to help you find the most up-to-date and accurate information when you’re looking to find or get basic information about an in-network doctor, hospital or other healthcare provider.

The amount of covered expenses an individual must pay before benefits are paid by Blue KC. See also deductible and family deductible.

Under the Affordable Care Act, starting January 1, 2014, all U.S. citizens and legal residents are required to enroll in minimum essential coverage. Some individuals may also be eligible for an exemption from this mandate.

Cases in which the effectiveness and/or safety of a healthcare service has not been established. Benefits are not available for investigational healthcare services. Please see the Exclusions and Limitations sections of your certificate or contract for more information.

Lethal means safety is a suicide-prevention practice that involves making a suicide attempt method less available or more difficult to access immediately, therefore less likely to cause a fatal suicide attempt.

The maximum dollar amount or number of services or visits that Blue KC will cover over the duration of a member’s health insurance policy. Blue KC will not pay for services beyond this maximum.

A federal government program that provides healthcare services to low-income individuals and/or families. Learn more about Medicaid.

A federal government program that provides health insurance to anyone ages 65 and older, to anyone with permanent kidney failure and to certain people with disabilities. Medicare consists of four parts:

Medicare Part A helps cover inpatient care in hospitals and skilled nursing facilities and hospice care.
Medicare Part B helps cover doctor services and outpatient care.
Medicare Part C is provided through private insurance companies approved by Medicare that provides lower costs and expanded benefits.
Medicare Part D may help lower the cost of prescription drugs. Learn more about Medicare Parts A, B and C. Learn more about Medicare Part D.

An individual covered under a health insurance plan provided by Blue KC. See also covered person.

A member ID card includes the member’s name, member and group identification numbers, healthcare plan name, copayment amounts and customer service phone numbers. Members should always have their member ID card with them because it is typically required at every office, hospital and pharmacy visit. To order a temporary or replacement member ID card, log in, click the My Account tab. You can request a temporary card or order a new member ID card.

A mental health condition or mental disorder is a diagnosable disorder that affects a person’s thinking, emotional state, and behavior. It disrupts the person’s ability to work, carry out daily activities, and engage in satisfying relationships.

A state of well-being in which a person realizes their own abilities, can cope with the normal stresses of everyday life, can work productively and fruitfully, and can contribute to their community.

Awareness of one’s internal state and surroundings. The concept applies to various therapeutic interventions to help people avoid destructive or automatic habits and responses by learning to observe their thoughts, emotions, and other present-moment experiences without judging or reacting to them.

A level of coverage that includes many different kinds of health insurance, including individual coverage, coverage through an employer, Medicare, Medicaid, CHIP or TRICARE. Individuals who don’t purchase minimum essential coverage and who do not obtain an exemption may be subject to a penalty when they file their taxes in 2015.

A hospital, pharmacy, physician or other medical service provider that does not have a contract with Blue KC or another Blue Cross and/or Blue Shield plan to provide healthcare services to members. Depending on the member’s plan, services from a non-participating provider may or may not be covered. A non-participating provider is also referred to as an out-of-network provider. PPO members who visit a non-participating provider will receive limited benefits; HMO members will not receive any benefits except in the case of an emergency.

Non-preferred drugs have a higher cost than preferred brand drugs. Generally these are higher-cost medications that have recently come on the market. So-called “designer” drugs also fall into this category.

A hospital, pharmacy, physician or other medical service provider that does not have a PPO contract to provide healthcare services to Blue KC members. A non-preferred provider is also referred to as an out-of-network provider.

Open enrollment, also known as annual enrollment, is a period of time usually, but not always, occurring once per year, when employees may make additions, changes or deletions to their elected benefit options. In most cases, employees can only make changes in benefits elections during open enrollment or when they have experienced a specific qualifying event like the birth of a child or marriage. During this time period, an employer will typically communicate to all eligible employees what options they have for their benefit program. Open enrollment is your opportunity to review your health insurance and spending accounts benefits coverage and make choices for the upcoming calendar year. You should actively enroll during open enrollment to ensure your benefits meet your needs.

A hospital, pharmacy, physician or other medical service provider that does not have a network contract with Blue KC to provide healthcare services to members. Both non-participating providers and non-preferred providers are also referred to as out-of-network providers. PPO members who visit an out-of-network provider will receive limited benefits. HMO members will not receive any benefits except in the case of an emergency.

A hospital, pharmacy, physician or other medical service provider that participates in a Blue KC network and accepts allowable charges as payment for covered services. If a participating provider also has a PPO contract, the provider will be considered an in-network provider (an important distinction for PPO members).

The PCMH is a model of healthcare based on an ongoing, personal relationship between a patient, doctor and the patient’s care team. Whatever the medical needs, primary or secondary, preventive care, acute care, chronic care, or end-of-life care the patient has a medical “home” as a single, trusted doctor and care team, through which continuous, comprehensive and integrated care is provided.

A Personal Care Account is funded by an employer. Members can use money in their PCA to pay for eligible medical expenses. Members can roll over any unused funds each year, and employers can establish limits on the rollover amount.

A medical condition for which medical advice, diagnosis, care or treatment was received or recommended during the 90 days prior to the first day of the member’s pre-existing condition exclusion period. See your certificate or contract for more information. See also pre-existing condition exclusion period and certificate of creditable coverage.

The period of time specific services are not covered related to a pre-existing condition. See also pre-existing condition and certificate of creditable coverage.

Preferred are drugs for which generic equivalents are not available. They have been in the market for a time and are widely accepted. They cost more than generics, but less than non-preferred brand-name drugs.

A hospital, pharmacy, physician or other medical service provider participating under a contract with Blue KC in a preferred provider organization (PPO) that accepts allowable charges as payment for covered services. A preferred provider is also referred to as an in-network provider and may be a participating provider.

A list of prescription drugs covered by health insurance plans that include prescription drug coverage. Refer to your certificate or contract to find out whether your plan includes this benefit. Prescription drugs are listed as Tier 1, Tier 2 or Tier 3, which determines the cost the member will pay for a medication. Learn more about the Prescription Drug List.

The physician who a member chooses as his or her primary physician for medical care. Primary care physicians typically specialize in one of four fields of medicine: family practice, general practice, internal medicine or pediatrics. HMO members are required to have a PCP on file.

The process requiring approval before health insurance is authorized for a specific drug or medical service.

A process that uses utilization review to determine the necessity of a service, admission to a healthcare facility or approval for treatment prior to services being provided. See also concurrent review and utilization review.

Something that decreases the chances of developing a condition and/or balances out an existing risk factor.

A hospital, pharmacy, physician or a medical service or facility that provides healthcare services.

A shared belief held by members of a team that it is OK to take risks, to express their ideas and concerns, to speak up with questions, and to admit mistakes – without fear of negative consequences.

An abnormal mental state involving significant problems with reality testing. It is characterized by serious impairments or disruptions in the most fundamental higher brain functions – perception, cognition and cognitive processing, and emotions or affect – and manifests itself in behaviors, such as delusions, hallucinations, and significantly disorganized speech.

Insurance plans sold through a federal or state Marketplace must be certified as Qualified Health Plans. These plans have to meet all of the standards required by the ACA, as well as some additional standards.

The process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility, and adjustment to external and internal demands.

Something that increases the chances of developing a condition.

Midlife adults who simultaneously care for dependent children and ailing parents or other older relatives. Being a multigenerational caregiver can negatively affect health and behavior by decreasing one’s level of exercise, increasing one’s frequency of cigarette smoking, and increasing one’s risk of depression.

A mood disorder in which there is a predictable occurrence of major depressive episodes, manic episodes, or both at particular times of the year, such as during the fall or winter months.

The opportunity or requirement to have a second provider review your health status and any proposed healthcare services and/or treatments.

An arrangement of certain covered services that must be performed by a specific contracted provider. If services are performed by a provider not listed in the contract, those services will not be covered or will be paid at a lower level.

Activities required for personal care, such as eating, dressing, or grooming, that can be managed by an individual without the assistance of others.

A facility that provides 24 hour nursing services including rehabilitation and long term illness care.

Techniques for the treatment of insomnia that involve following certain routines aimed at improving sleep patterns, such as using the bed only for sleeping and sex, not napping during the day, decreasing caffeine intake or eliminating it after a certain point in the day, going to bed regularly at a set time, and keeping a sleep diary.

The period of time in which an individual who did not initially enroll for coverage may elect to enroll and/or a new dependent may enroll for coverage if specific criteria are met. Members may also elect to make changes to their coverage based on life changes or events such as a marriage or the birth of a child.

Doctors of medicine (MD), osteopathy (D.O.) and other medical practitioners who specialize in a particular branch of medicine. For example a cardiologist, allergist or OB GYN.

Specialty drugs are high-cost injectable, infused, oral, or inhaled drugs that generally require special storage or handling and close monitoring of the patient’s drug therapy.

The negative social attitude attached to a characteristic of an individual. The negative social attitude may be regarded as a mental, physical, or social deficiency. A stigma implies social disapproval and can lead unfairly to discrimination against and exclusion of the individual.

The physiological or psychological response to internal or external stressors. Stress involves changes that affect nearly every system of the body — palpitations, sweating, dry mouth, shortness of breath, fidgeting, accelerated speech, augmentation of negative emotions – influencing how people feel and behave.

The primary member listed on the insurance policy. A subscriber and any of his or her enrolled dependents receive the benefits of a health insurance plan.

The recurring use of a substance (legal or illegal) to the point that it interferes with the user’s responsibilities and/or physical health.

Death caused by injuring oneself with the intent to die.

The Summary of Benefits and Coverage (SBC) provides a standardized overview of your benefits including copayment amounts, cost estimates for common medical events and a glossary with standard definitions for common medical and insurance terms. SBC’s were designed to help you better understand and evaluate your health insurance choices.

A generic drug that contains the same active ingredients as a brand name drug and has the lowest copayment. For example Ranitidine is the generic version of the brand name drug Zantac.

Brand name drugs that have a mid-range copayment option (Tier 2 medications) or the highest copayment option (Tier 3 medications). Tier 3 also includes medications not on a prescription drug list, medications with an available generic equivalent and new drugs that are being reviewed.

Total Care is coordinated, patient-focused healthcare. Total Care doctors focus on their patients’ overall healthcare needs – providing preventive services, wellness coaching, chronic condition management, and more. As your patient advocate, your primary care provider (PCP) will work with you to develop and coordinate a total care plan. Your PCP will also work with any specialist you might need along the way. Get healthy faster. Stay healthy longer. And lower healthcare costs over time.

A formal review conducted by licensed registered nurses of healthcare services, procedures and/or hospital admissions. The review looks at several aspects of care including determining the medical necessity of in-patient care. See also concurrent review and prospective review.

vCard is a standard that defines the format of an electronic business card. All devices supporting vCard can exchange contact information such as phone numbers and addresses.

Susceptibility to developing a condition, disorder, or disease when exposed to specific agents or conditions.

The length of time an employee must continuously work for an employer before the employee is eligible for coverage.