GLOSSARY

Injury to the body sustained in an accident.

Is accomplished through successfully passing a review of our business practices against published standards performed by an external certifying agency like NCQA or URAC.

Actuarial value (AV) is the percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30%–in the form of deductible, copayments or coinsurance–of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual healthcare needs and the terms of your health insurance plan.

Processing claims according to a contract.

The period of time that a member is a registered patient at a hospital or skilled nursing facility.

The maximum amount that is payable to you under your health insurance plan for a particular healthcare service. Contracted providers have agreed to accept this amount as payment in full. For example, if the provider charges $100 for a service and Blue KC pays $80 as the allowable charge, the provider cannot ask the member to pay the remaining $20. Keep in mind, however, that some health insurance plans have coinsurance. In those cases, members are required to pay a percentage of the allowable charge. For specific details about your plan, review your certificate or contract.

The annual enrollment period determined by an employer and Blue KC when an eligible employee and his or her dependents can enroll for health insurance or make changes to current health insurance coverage.

A national program that offers HMO members access to a participating HMO provider out of the Blue KC service area. Blue KC designed this program for subscribers who have a child attending school out of the Blue KC service area, have dependents living in different service areas, have a long-term work assignment in another state and/or are a retiree with dual residence. Find the names and locations of providers participating in the Away From Home Care Program®. See also BlueCard® Program.

The bill that a provider sends to a member for charges that exceed the allowable charge. For healthcare services obtained from a non-contracted provider, the member may have to pay bill amounts above the allowable charge.

A listing of certain covered healthcare services defined in the member’scertificate or contract that specifies copayments, coinsurance, deductibles and coverage exclusions.

A national federation of 37 independent and locally operated Blue Cross and Blue Shield companies, including Blue Cross and Blue Shield of Kansas City (Blue KC). Learn more about the Blue Cross Blue Shield Association.

The Kansas City area’s largest and only locally managed commercial health insurance provider. Blue KC is an independent licensee of the Blue Cross and Blue Shield Association and serves nearly one million members. Learn more about Blue KC.

A national preferred provider program that offers members who travel or live outside the Blue KC service area PPO benefits when they receive covered services from a preferred provider. See also BlueCard® PPO Program Service Area.

The service area of Blue KC and any other service area of a Blue Cross and/or Blue Shield plan participating in the BlueCard® PPO Program. See also BlueCard PPO Program.

A national program that offers PPOmembers the ability to receive healthcare services while traveling or living in another Blue Cross and/or Blue Shield service area. Find the names and locations of providers participating in the BlueCard Program. See also Away From Home Care®.

A prescription medication that may or may not have a generic equivalent. A generic equivalent cannot be manufactured until the original brand name patent has expired. A brand name drug is a more expensive version of a generic equivalent, if a generic drug exists, see also Tier 2 and Tier 3.

January 1 through December 31 of the same year.

The maximum dollar amount or maximum number of days, visits or healthcare sessions that a member has healthcare coverage in one calendar year. If a member exceeds these maximums, no more benefits for such covered services will be provided during the same calendar year. For example, a member’s health insurance plan might cover 26 chiropractic visits a year. The member would have to pay 100 percent for additional visits.

A case manager typically works with a member receiving in-patient hospital care. The member has to receive a referral to work with a case manager who helps coordinate a member’s care and collaborates with family members and physicians. Case managers recommend programs to help members manage ongoing health conditions and provide supporting educational materials.

A document that outlines the benefits, exclusions, responsibilities, rights and other important information related to a member’s group health insurance plan.

A certificate that documents prior healthcare coverage and may be used to reduce a pre-existing condition exclusion period on group health insurance plans. See also Creditable Coverage.

A request for payment that a member or provider sends to Blue KC for healthcare services performed. See also adjudication.

The percentage of an allowable charge that a member pays not including any copayments or deductibles. For example, if the member’s plan has an 80/20 coinsurance rate, Blue KC will pay 80 percent of the allowable charge for eligible medical expenses and the member will pay the remaining 20 percent.

Blue KC conducts a utilization review during a member’s hospital stay ordering the course of medical treatment to ensure that these services are medically necessary and eligible for coverage. See also prospective review and utilization review.

An uninterrupted stay at a hospital or skilled nursing facility from admission until discharge.

A law requiring some employers to offer continued health insurance coverage to employees whose coverage was terminated under certain circumstances.

An agreement between an employer and Blue KC that defines the terms of health insurance coverage. Terms include the employer’s application to provide coverage to members and the member’s application to request to receive coverage. The contract also includes the member’s certificate, which explains a member’s rights and any amendments to that certificate.

Coordinating with another health insurance plan to provide payment for healthcare services for a member who is covered under more than one health insurance contract.

The dollar amount that a member usually pays each time that a covered service is performed. If the member’s plan has a copayment amount, it is typically listed on the member ID card.

Cost-sharing assistance will limit a person’s maximum out-of-pocket costs, and for some it will also reduce other cost-sharing requirements (i.e., deductibles, coinsurance, and copayments). Households with incomes under 400 percent Federal Poverty Level will get subsidies to lower their cost sharing based on their income. View Federal Poverty Level guidelines.

Health insurance that a member receives for covered services.

The period during which a member has healthcare coverage as a result of the member and/or employer paying premiums on a timely basis.

An individual covered under a health insurance plan provided by or administered by Blue KC. See also member.

Healthcare services, supplies, equipment and care listed in a member’s certificate or contract, with the exceptions of excluded conditions and limitations that are identified in the certificate or contract.

Certain prior healthcare coverage that a member had that might be used to reduce a pre-existing condition exclusion period on group health insurance plans. See also certificate of creditable coverage.

Care to help a member perform normal daily activities, such as dressing or eating rather than providing medical treatment.

The date that a member receives healthcare services from a provider. This date is noted on the Explanation of Benefits that members receive.

The amount of covered expenses that must be paid by a subscriber in a calendar year before benefits are paid by Blue KC. See also family deductible and individual deductible.

A person in a subscriber’s family who meets eligibility requirements to become a covered person. For example, a subscriber’s spouse and/or children.

The process of coordinating and managing the care of a member before he or she is discharged from a medical facility.

Through the Blue KC Healthy Companion™ program, Blue KC members, with the exception of FEP members can receive education, tools and other resources to help them manage certain chronic diseases, such as high blood pressure, asthma, chronic obstructive pulmonary disease (COPD) and depression.

Electronic Funds Transfer (EFT) is a system of directly transferring money from one bank account to another without any paper money changing hands.

The determination of a member’s qualification for health insurance coverage.

Ambulance services and/or healthcare items and services used to evaluate and treat a member in an emergency medical situation.

A program typically offered by an employer that provides counseling services for subscribers and their eligible dependents to assist with everyday life challenges and stress management. If your employer has arranged for this benefit, log in and click the My Coverage tab to find more information about your EAP.

The Affordable Care Act includes a requirement that all non-grandfathered individual and small employer group plans must provide coverage for at least the following 10 categories of benefits:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

A statement sent to the member listing healthcare service(s) obtained, amount(s) paid by the plan and the total amount that a member may owe to a provider.

The amount of covered expenses that an entire family (a subscriber and all dependents) must pay before benefits are paid by Blue KC. See also deductible and individual deductible.

The Affordable Care Act provides two forms of subsidies to help pay for health insurance. First, a monthly premium assistance tax credit will lower the premium amount an individual or family must pay. Second, cost-sharing assistance will limit a person’s maximum out-of-pocket costs, and for some it will also reduce other cost-sharing requirements (i.e., deductibles, coinsurance, and co-payments). Eligibility is determined based on household income.

A less expensive drug that is chemically identical to its brand name equivalent but can only be produced after the brand name drug’s patent has expired. See also Tier 1.

If the individual or family plan you are enrolled in was in place on or before March 23, 2010–the day the Affordable Care Act (ACA) was enacted–the plan you purchased may now be considered a “grandfathered” plan, and may be exempt from many of the new mandates. However, some of the law’s requirements apply to all plans, including grandfathered plans.

A written complaint of the availability, delivery or quality of covered services or the payment, handling or reimbursement of healthcare services. To file a grievance, Contact Us.

The Health Insurance Marketplace, sometimes known as “the exchange”, is an online marketplace where individuals and small businesses can compare and buy affordable health insurance plans. On the Marketplace website, you may complete an application and find out if you qualify for financial assistance–known as Advance Premium Tax Credit–which can help lower your monthly premiums. You’ll also find out if you qualify for lower out-of-pocket costs. You can find the Health Insurance Marketplace at www.healthcare.gov.

A health insurance plan that provides a predetermined medical care benefit package and requires members to use providers in the plan’s network to receive benefits. See also HMO provider. If you are an HMO member, you will need to check to see whether a provider is an HMO provider. If a provider is an HMO provider, you will receive your benefits for covered services as outlined in your certificate or contract. If you choose to visit a non-HMO provider, you will not receive any benefits except in the case of an emergency. Please note, whether a provider is participating, non-participating, preferred or non-preferred does not apply to HMO members.

An HRA is the same thing as a Personal Care Account (PCA). It is commonly used with a high-deductible health plan such as Personal Blue. An HRA is funded by an employer. Members can use money in their HRA to pay for eligible medical expenses. They can roll over any unused funds each year, and employers can establish limits on the rollover amount.

An account that allows members enrolled in a qualified high-deductible health plan to contribute funds on a tax-free basis into the member’s account for payment of qualified medical expenses as defined by the IRS. A member’s employer may also contribute funds to the account. Unused funds in an HSA roll over in the member’s account at the end of each calendar year. Learn more about Health Savings Accounts.

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

A hospital, pharmacy, physician or other medical service provider who has entered into an HMO contract with Blue KC. The HMO contract establishes allowable charges for covered services.

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.

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.

A period of time when an individual is first eligible to enroll for healthcare coverage.

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.

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.

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.

Beginning with plans effective on or after January 1, 2014, the Affordable Care Act requires new individual plans offered on-or off- the Marketplace to provide coverage at designated “metal levels”–Platinum, Gold, Silver and Bronze. Platinum plans have the most generous coverage, and bronze plans have the least generous coverage.

• Platinum level plans pay 90 percent of benefits, on average
• Gold level plans pay 80 percent of benefits, on average
• Silver level plans pay 70 percent of benefits, on average
• Bronze level plans pay 60 percent of benefits, on average

There is also a catastrophic plan only available in the individual market that will cover the essential health benefits.

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:

1. Medicare Part A helps cover inpatient care in hospitals and skilled nursing facilities and hospice care.
2. Medicare Part B helps cover doctor services and outpatient care.
3. Medicare Part C is provided through private insurance companies approved by Medicare that provides lower costs and expanded benefits.
4. 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 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.

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.

Most benefit plans have an out-of-pocket maximum. If the total dollar amount that you have paid in deductibles, coinsurance, and in some cases copayments, reach this maximum amount in a calendar year, then Blue KC will pay 100 percent of the allowed charges for the remainder of the year.

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.

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 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.

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 health insurance plan that offers members a preferred network of healthcare providers who provide services for predetermined fees. Members who choose to use an out-of-network provider will generally pay a larger portion of medical expenses. If you are a PPO member, you will need to check to see whether a provider is in-network or out-of-network. Also, check to see whether the provider is participating or non-participating in a Blue KC provider network. All non-participating providers are considered out-of-network. Visiting these types of providers could result in limited benefits.

The amount a member or group pays on a periodic basis for coverage as defined in the member’s health insurance certificate or contract.

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.

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

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 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.

The geographic area served by Blue KC, which includes 32 counties in the greater Kansas City area and northwest Missouri. In Kansas, Blue KC serves Johnson and Wyandotte counties. In Missouri, we serve Andrew, Atchison, Bates, Benton, Buchanan, Caldwell, Carroll, Cass, Clay, Clinton, Daviess, DeKalb, Gentry, Grundy, Harrison, Henry, Holt, Jackson, Johnson, Lafayette, Livingston, Mercer, Nodaway, Pettis, Platte, Ray, Saline, St. Clair, Vernon and Worth counties. Not all HMO products are available in every Missouri county we serve. Contact Us for information regarding the HMO service area in Missouri.

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

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 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 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.

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