A
Affordable Care Act (ACA)
A law that helps more U.S. citizens get health care and helps to lower care costs.
Allowable Charge
The amount your health insurer pays a doctor, hospital or other provider for the care they give you.
Annual Limit
The total amount your health plan will pay for your covered care in a year.
B
Balance Billing
A bill showing the difference between how much you need to pay an out-of-network provider and what you don’t need to pay because it is covered by your health plan.
Benefits
All the health care that is covered by your health plan.
Benefit Booklet
A booklet you get when you join a health plan that explains details of your benefits.
Billed Amount
The total amount a provider charges for the care you get from them.
Binder Payment
The first month's premium payment you make to an insurance company after you enroll in a new health plan. After you make the binder payment, you can start using your benefits.
Blue Access for MembersSM (or BAM)
A secure, user-friendly portal where you can learn about your health plan 24/7. Topics on the portal include what is covered, your claims and how to reach customer service.
C
Catastrophic Plan
A health plan you may be able to get if you are under the age of 30 and qualify for a hardship or affordability exemption.
Children’s Health Insurance Program (CHIP)
A federal program that gives low-cost health coverage to the children in your family if you earn too much money to get Medicaid.
Claim
A statement showing the cost of your health care service.
Claim Form
A form that you or your provider send to your health insurer for repayment after care is given.
COBRA
A federal law that helps you keep your health coverage for a short time when certain life events cause you to lose coverage. Examples of these may be the loss of your job or the loss of your parents’ coverage.
Coinsurance
The share of costs, either a percentage or set amount, that you pay for covered health care or prescription drugs. You need to meet your deductible before coinsurance applies.
Consumer Directed Health Plan (CDHP)
A health plan that gives you a health savings account (HSA) or other tax-advantaged account.
Contracted Provider
A provider that has a contract with BCBSMT to give you care for a discounted amount.
Coordination of Benefits
When two or more health plans figure out which pays for certain costs in your health claim. Sometimes, one of them pays for all the costs.
Copay
A set amount you may pay each time you see a provider or get a prescription filled.
Cost-Sharing Reduction (CSR)
A discount that lowers the amount you pay for deductibles, coinsurance and copays.
Covered Person
A person who joined a health plan and their eligible dependents.
Covered Service
A health service that is covered by your health plan.
D
Deductible
A set dollar amount you pay in full for your care before your health plan starts to pay.
Dependent
A person (often a spouse or child) who has health care benefits under your plan.
Drug List (or Drug Formulary)
A list of preferred brand and generic drugs that are covered by your health plan. These drugs are chosen by a panel of doctors and pharmacists.
E
Effective Date
The date, month and year your health coverage starts.
Emergency Care
Care to treat a health problem that may threaten your life.
Employer Shared Responsibility Payment (ESRP)
Taxes an employer with 50 or more full-time workers must pay if the health plan they offer doesn’t meet the basic care standards set by ACA.
Essential Health Benefits
Care that is seen as vital to your good health that health plans must cover. These may be doctors’ services, inpatient and outpatient hospital care, prescription drugs, and more.
Exclusions
Some services that your health plan may not cover.
Explanation of Benefits (EOB)
A statement you get from your health insurer after getting health care which shows the costs that are covered by your plan.
F
Family Health Plan
A health plan that covers you, your spouse or partner and your dependents.
Federal Poverty Level (FPL)
An individual or household yearly earnings level used by the Department of Health and Human Service. Your FPL may help you get savings on Marketplace health insurance, Medicaid and CHIP coverage.
Flexible Spending Account (FSA)
A special savings account with money in it. It is set up by your employer to help you pay for your eligible out-of-pocket health care costs.
G
Generic Drug
A prescription drug that isn’t a name-brand drug. However, it works just as well as the name-brand drug and costs you a lot less.
Grandfathered Health Plan
Pre-ACA health plans that don't need to meet some requirements.
Group Health Plan
A health plan offered by an employer or organization that gives you, its other workers and your families, health coverage.
Guaranteed Issue
This part of ACA ensures health insurers accept you if you want to sign up for health care coverage. You can’t be rejected based on your health status, age, gender or other factors.
H
Health Care Facility
Any place that gives you health care services. These may be a hospital, a skilled nursing facility, a diagnostic lab or imaging center and more.
Health Coverage
A plan that covers the payment of some of your health care costs at a discount.
Health Insurance Marketplace
A federal website where you can shop for health plans and compare prices. You can also use it to buy health plans from health insurers in your area.
Health Insurer
A company that offers health plans. The plans must meet insurance laws and regulations.
Health Maintenance Organization (HMO)
A health plan that uses a network of doctors, hospitals and other providers. HMOs rely on a primary care doctor (PCP) to arrange your total care.
Health Plan
A plan that pays for certain health care services you get. These may be doctor or physician visits, prescription drugs, and medical tests.
Health Plan Year
A one-year period that starts on your health plan contract start date/anniversary and ends the day before your next contract date/anniversary.
Health Savings Account (HSA)
An account where you can put and withdraw money tax-free to help pay for some health care costs.
HIPAA
This privacy law protects your sensitive medical and personal information from being shared with others without your permission.
Home Health Care
Care in which a health professional visits you at home. They usually track your ongoing health issues or your recovery after a hospital stay.
Hospice Services
Services that offer you comfort and support, such as reducing pain and managing symptoms, if you are in the last stages of a terminal illness.
I
Individual Coverage HRA (ICHRA)
A health plan that employers can offer when they don’t provide a group health plan, which helps individuals cover some of the costs of their health care.
Individual Health Plan
A health plan you can buy for yourself and your eligible family members if you don’t have coverage through your job.
Infusion Therapy
Medicine that is delivered in liquid form straight into your bloodstream. It is often used to treat life-long health issues.
In-Network
Doctors, hospitals and other providers who work with health insurers to offer you care at the best possible prices.
Inpatient Care (or Hospitalization)
Health care that happens in a hospital or inpatient care facility that requires you to stay overnight.
Imaging
Any scan of your body using imaging equipment to find a health issue. They may be an X-ray, CAT, MRI or ultrasound.
J
K
L
Lifetime Limit
A limit on the total benefits you get from your health insurer over the life of your plan. After this, the health plan no longer pays for your care.
Long-Term Care
Care you can get at home, in an assisted living facility or nursing home. It is often offered if you’re not able to do basic acts like dressing or bathing without help.
M
Medicaid
A federal program that offers no cost or low-cost health plans. People who can get Medicaid often are those with low household income, families and children, pregnant women, the elderly and people with certain chronic disabilities.
Medical Cost-Sharing Group
A group, often a nonprofit, with members who share costs for a health plan. The plan isn’t offered by a health insurer.
Medical Group
A group of doctors and health experts who contract with a health insurer together to give care to you.
Medically Necessary (or Medical Necessity)
Health services that a provider and health insurer decide you need.
Medicare
A federal health insurance program that offers health coverage to some groups of people. These people are often those who are 65 and older, younger people with disabilities, those with end-stage renal disease, and ALS (Lou Gehrig’s disease).
Member
You are a member if you are covered by a health insurer. Your coverage can be as a single person or as an eligible dependent.
Member ID Card
The card BCBSMT gives you after you enroll in a health plan. The card includes your member ID number, group number and important information about your plan.
N
Network
A group of doctors, hospitals and other providers that are contracted by BCBSMT to give you care at lower prices.
Non-Contracted
A provider that is out-of-network and isn’t contracted by BCBSMT to give care to you.
Non-Covered Service
A health care service that isn’t covered and not paid for by your health plan.
O
Open Enrollment Period
A limited period of time once a year where you can join a health plan.
Out-of-Network
Care given by a doctor or other provider who isn’t contracted by your health plan. Going to these providers may lead to costs that aren’t covered by your health plan.
Out-of-Pocket Costs
The costs you pay for care that aren’t covered by your health plan.
Out-of-Pocket Maximum (or Out-of-Pocket Limit)
The most you need to pay for you or your family’s care in a year before your health plan pays 100% of it. Your health plan will then pay up to the allowed amount.
Outpatient Care
Care that doesn’t need you to stay overnight in a hospital or another inpatient care facility.
P
PPO
A health plan with a network of providers who agree to give care to you for set prices.
Pharmacy Benefit Manager (PBM)
A company that handles prescription drug benefits for health plans, Medicare Part D plans, large employers and other payers. It helps to lower your drug costs.
Preferred Provider
A doctor who works with your health insurer to give your health services at a lower cost to save you money.
Preferred Pharmacy
An in-network pharmacy that gives you the lowest out-of-pocket cost on a covered prescription.
Premium
The amount of money you pay monthly, quarterly or yearly to be covered by your health plan.
Prescription Drugs
FDA-approved drugs that must be ordered by your doctor and filled by a pharmacy.
Prescription Drug List Tier
Different payment levels you may need to pay based on the cost of different drugs.
Preventive Care
Routine health screenings, exams and counseling to help you avoid sickness, disease and life-long health issues.
Primary Care Provider (PCP)
A doctor, nurse practitioner or physician aide who is your main health go-to and who can arrange all your care.
Prior Authorization (or Preauthorization)
An approval you may need to get before getting certain health care services, treatments, prescription drugs or health equipment. Without this approval, they may not be covered by your health plan.
Provider
A doctor, dentist or other health professional that gives your health care services.
Q
Qualifying Life Event
An event that lets you sign up for a health plan outside the open enrollment period.
Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)
A health plan that helps small companies pay for their employees’ monthly premiums and other health care costs if they can’t pay for group health coverage on their own.
R
Referral
A written order from your primary care doctor (PCP) to see a specialist or get certain health services. A referral may be needed for your health plan to pay for the cost of the services.
S
Skilled Care
Skilled nursing or rehab you get, that are supplied by licensed health professionals like nurses and physical therapists. This care is often given after an injury, surgery or to help you manage life-long sickness.
Skilled Nursing Care Facility
A residential facility where you are given a high level of care and support 24/7.
Specialist
A provider who is a trained expert on a specific area of health. This may be a certain system in your body, a disease or a treatment.
Special Enrollment Period
Time outside of open enrollment when you can sign up for a health plan. You can do this if you have a life event that changes your coverage, like marriage, a new job, or retirement.
Specialty Drug
A prescription drug you may use to treat complex health issues. The drug often has special handling needs and isn’t often sold in retail pharmacies.
State Continuation Coverage
COBRA-like health plans that some states require small companies with less than 20 people to offer to workers who lose their job.
Subscriber
You are the subscriber of a health plan if you are the primary person on the account. If you are the subscriber, you are responsible for paying costs associated with your plan and you can enroll dependents.
Subsidy (or Premium Tax Credit)
A tax credit you may qualify for based on your household earnings and family size. It can be used to lower your insurance premium.
Summary of Benefits and Coverage (SBC)
An overview document you get when you shop for health plans or renew or change coverage. It lets you compare the costs and coverage of health plans.
T
Therapeutic Alternative
A drug that is chemically different from the drug prescribed to you, but that has the same clinical effect as your prescribed drug.
U
Urgent Care
Care for an illness, injury or condition that you need immediate attention for. However, it isn’t serious enough to go to an emergency room (ER).
Utilization Management
A review process that looks at the type and amount of care you get, where it was given and if there is a medical need for you to get it.
V
W
Waiting Period
The time before your health insurance goes into effect for you and your dependents if you are covered through your job.
X
Y
Z
To learn more about these topics, check out the articles on Connect.