Benefit Key Terms
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The maximum negotiated contract rate a health plan will pay for a covered service or treatment. The allowed amount is determined by each health plan.
The amount you must pay each calendar year for covered services before your medical plan pays benefits. Expenses incurred by two or more individuals can be applied to the family deductible. This amount applies to your out-of-pocket limits.
The portion of medical services, usually a percentage that the employee must pay in addition to the deductible.
Coordination of Benefits (COB)
When two or more group health insurance plans cover the employee and their dependents, one plan becomes the primary and the other plan(s) the secondary. Medical expenses not covered under the primary plan may be covered under the secondary plan of the spouse. The employer's plan is always primary for an employee. Covered dependents' primary plan is determined using the "birthday rule," meaning the health plan of the parent whose birthday comes first in the calendar year is designated as primary. Note that it doesn't matter which parent is older, because the year is not a factor.
The fixed amount you pay directly to the provider at the time services are rendered. Co-pays DO apply to your annual out-of-pocket limits.
A group of doctors, hospitals and other health care service providers that contract with our BlueCross BlueShield medical plans to provide quality health care services at favorable rates.
Providers outside of the plan's network. Services are subject to higher deductibles and coinsurance, and in some cases, are not covered at all.
The maximum dollar amount per year of eligible medical charges payable by the member. Once you reach the out-of-pocket maximum, your medical plan pays 100% of covered expenses for the rest of the year. Any co-pays for services, such as physician office visits and prescriptions, do not apply to this limit.
The plan year for benefits begins January 1 and ends December 31.
Requires that either you or your doctor appropriately notify the plan provider and receive authorization before you receive certain services, otherwise benefits will be reduced.
Reasonable and Customary Charges (R&C)
The most a plan will consider eligible for a covered expense. R&C charges are determined by each medical plan and are based on the range of fees charged by doctors with comparable training and experience for the same or similar service in your area.