Website Definitions
Benefit Period
A specified period of time during which benefits for covered services
must be used. For example, a calendar year (January-December) or a
contract year (the 12 consecutive months following your effective date
of enrollment).
Benefit Period Maximum
The total amount your insurance plan will pay for covered medical
expenses during each benefit period.
Calendar Year
The 12-month period beginning on January 1 and ending on December 31.
Coinsurance
A cost-sharing requirement under which you are responsible for paying a
certain percentage of the covered medical expenses, after your meet your
deductible (if applicable).
Contract Year
The period of 12 consecutive months following the effective date of your
agreement and each subsequent 12-month period that the agreement is in
effect.
Co-payment
A cost-sharing requirement under which you are responsible for paying a
set dollar amount for covered medical expenses, after you meet your
deductible (if applicable).
Deductible
Amount you must pay out of your own pocket before the plan begins to pay
for any covered services.
Determining HIPAA Eligibility
For HIPAA eligible individuals: Health care coverage options that cover pre-existing conditions are available to individuals who meet the eligibility requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. If you live in the 21 counties of central Pennsylvania and the Lehigh Valley served by Highmark Blue Shield and meet the following guidelines, you may be eligible to enroll in either High Option $750 Deductible ClassicBlue Comprehensive Major Medical or Basic Option $1,500 Deductible ClassicBlue Comprehensive Major Medical. Parents of HIPAA Eligible children who do not elect HIPAA Coverage for themselves may still enroll their children in one of these Plans.
To be HIPAA eligible:
- You must have a minimum of 18 months of prior creditable health care coverage (with no breaks in coverage of more than 63 days each) and your last coverage was provided through a group, governmental or church plan.
- You must submit your substantially completed Application to Highmark Blue Shield within 63 days from the date that your most recent insurance coverage ended.
- You must have used all of the "COBRA" benefits available to you through your former employer.
- You are not eligible for or enrolled in Medicare, Medicaid or any other group, governmental or church health insurance plan.
- You do not have any other health insurance coverage.
Highmark Blue Shield accepts Certificate(s) of Creditable Coverage from your prior plan(s) to demonstrate that you have the minimum 18 months of prior creditable coverage. If you do not have a "Certificate(s) of Prior Creditable Coverage", you may still demonstrate your prior coverage by:
A.
(i) attaching your own written statement regarding your prior coverage that includes the name(s) of the plan(s) that provided your last eighteen (18) months of coverage, including the beginning and end date(s) of all such coverage; and
(ii) attaching copies of any documents you may have evidencing that you had coverage during those dates such as a copy of an identification card, an explanation of benefits (EOB), premium invoices or pay stubs evidencing payroll deductions for health care coverage, etc.; and
(iii) signing Section B. of the HIPAA Prior Coverage Disclosure and Authorization Form attached to the Application;
-OR-
b.
(i) completing Sections A. and B. of the HIPAA Prior Coverage Disclosure and Authorization Form attached to the Application and returning it with your Application; and
(ii) attaching copies of any documents you may have evidencing that you had coverage during those dates such as a copy of an identification card, an explanation of benefits (EOB), premium invoices or pay stubs evidencing payroll deductions for health care coverage, etc.
Regardless of which method you choose, you must also cooperate with Highmark Blue Shield efforts to verify your prior coverage. Your cooperation includes signing Section B. of the HIPAA Prior Coverage Disclosure and Authorization Form which gives Highmark Blue Shield authorization to request a certificate or other coverage information directly from a previous plan or insurer on your behalf. Prior creditable coverage may also be established through means other than documentation, such as telephone verification.
If you would like more information about HIPAA, call our Member Service Department at 1-877-986-4571.
Effective Date
The date, as shown in our records, on which your health care coverage
began.
Guaranteed Issue
Plans that accept all applicants without regard to the applicant’s state
of health.
Health Savings Account (HSA)
A savings account for out-of-pocket medical expenses in which
contributions and interest earned are tax-exempt and withdrawals are
tax-free if funds are used for eligible medical expenses. An HSA is used
in conjunction with a high deductible health plan.
High Deductible Health Plan
(HDHP)
A health plan that offers substantial savings in monthly premiums in
conjunction with higher-than-usual deductible levels. When you enroll in
a qualified HDHP, you may be able to take advantage of the tax savings
offered by a Health Savings Account (HSA).
Health Maintenance
Organization (HMO)
A health care program that provides coverage only for those eligible
services received within the insurance carrier’s provider network. There
is no reimbursement to you if you use a doctor or hospital that does not
participate in the carrier’s network (unless it is an emergency).
Indemnity
Traditional fee-for-service health coverage in which covered services
received from participating providers are paid-in-full after any
applicable deductibles, co-payments or coinsurance.
Lifetime Maximum
The total amount your insurance plan will pay for covered medical
expenses while you are enrolled in your plan.
Medically Underwritten
Plans that base acceptance for enrollment on your health status,
determined by the answers you give on a medical questionnaire.
Network
Facilities, physicians and other health care providers that have
agreements with Highmark to accept the amount Highmark will pay for
covered services as payment- in-full after any applicable deductibles,
co-payments or coinsurance.
Non-participating Providers
Providers that do not have agreements with Highmark to accept our
payment amounts. These providers may “balance bill" you for any
differences between the Highmark payment amount and the provider’s
actual charges.
Out-of-network care
Services received from providers that do not have agreements with
Highmark. Some products include coverage at a lower level for
out-of-network care; others, like an HMO do not provide coverage if you
receive non-emergency care from a provider not included in Highmark’s
network.
Out-of-pocket Maximum
The maximum amount you will pay out of your own pocket for covered
medical expenses during a given benefit period.
Participating Providers
Providers that have agreements with Highmark to accept our payment
amounts as payment-in-full for covered services (after any applicable
deductibles, co-payments or coinsurance).
Pre-existing Condition
A condition for which medical advice or treatment was recommended by a
physician or other medical provider within a five-year period
immediately before your effective date of coverage.
Preferred-Provider Program
A health care program that provides coverage for eligible services
received both in and out of the program’s provider network. In-network
care is provided at a higher benefit level.
Programs Based on Income
Plans for which your eligibility is based on income guidelines.