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:

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.

-OR-

b.

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.