Allowable Charge – The allowance for the service(s) rendered or the provider’s billed charge, whichever is less based on the provider’s geographic area.
Balance Billing – Refers to the process of a health care provider charging a patient for the difference between the actual charge for services and the amount a managed
health care plan is willing to pay.
BCBS Participating Provider (“par”) – Individual physicians, hospitals and professional health care providers who have a contract with CareFirst BlueCross BlueShield
and/or CareFirst BlueChoice, Inc. to provide services to its members at a discounted rate and to be paid directly for covered services.
Beneficiary – The person(s), estate, trust or organization designated to receive benefits in the event of death.
Brand-Name Drug – A drug developed and produced exclusively by a single pharmaceutical company. The formula is protected by patent for a period of several years
before a generic equivalent can be developed.
Coinsurance – The percentage amount a plan member pays for certain covered health care services and supplies after the deductible has been met.
Copayment – The fixed amount a plan member pays when certain covered health care services and supplies are received.
Covered Expense – An expense for a service or supply that is covered under the applicable plan.
Deductible – The initial health care expenses each year that a plan member must pay before plan benefits are paid.
Dependent Care Reimbursement Account (DCRA) – An
arrangement through which Flexible Spending Account plan participants may set aside a portion of their pre-tax salaries to pay for certain eligible dependent care expenses.
Evidence of Insurability – A statement or proof of a ’s physical condition or other factors affecting his/her acceptance for insurance.
Formulary – Generally, a drug list used as a guide for determining the copayment or coinsurance amount health plan members pay for each prescription. Health plan
members generally pay a lower amount for drugs listed on the formulary. A formulary may also be referred to as a preferred drug list.
Generic Drug – A prescription drug, which is chemically equivalent to a brand-name product, and is dispensed under its generic chemical name.
Health Care Reimbursement Account (HCRA) – An arrangement through which Flexible Spending Account plan participants may set aside a portion of their pre-tax
salaries to pay for certain eligible health care expenses.
HMO (Health Maintenance Organization) – A health care delivery system that typically uses contracted primary care physicians to coordinate all health care for enrolled
members. HMOs may require each member to select a primary care physician (PCP). The PCP coordinates care and makes referrals to specialists and hospitals as needed.
Covered services are usually paid in full after the member pays any required copayment amounts. Claim forms are generally not required.
Imputed Income – The dollar value of certain benefits, such as coverage for a legally domiciled adult (LDA), that is viewed by the IRS as taxable income to the employee.
Georgetown reports imputed income on W-2 forms and the amount is added to other compensation.
LDA – Legally domiciled adult is a category of individuals eligible for coverage under Georgetown’s medical, dental and vision plans. See page 11 for details regarding
Lifetime Maximum – The maximum amount the plan will pay in benefits for each member during his/her lifetime.
Medically Necessary – Health care service or treatment that is generally accepted in medical practice as being needed for the diagnosis or treatment of a patient’s
condition and that cannot be omitted without harming the patient as judged against generally accepted standards of medical practice.
Network Providers – A group of doctors, hospitals, and other health care providers that have agreed to accept a negotiated fee for services rendered under a certain health
care plan. The continued participation of any specific provider cannot be guaranteed as contracts may be terminated at any time.
Non-Formulary Drug – A prescription drug that is not included in a health care plan’s formulary. Drugs not listed on the formulary typically require a higher
copayment from a plan member.
Non-Par – A provider who does not participate in either the BlueChoice network or “par” network. With “nonpar” providers a plan member may be billed for amounts over the BCBS allowable charge.
Open Enrollment – The period each year (usually in November) when employees have an opportunity to elect or make changes to medical, dental, vision, and
FSA elections. Elections made during open enrollment generally take effect the following January 1.
Out-of-Pocket Maximum – Generally, the maximum dollar amount -including deductibles, copayments and coinsurance -that a plan member pays in any calendar
year toward the cost of covered medical care. Once a plan member reaches the out-of-pocket maximum, the health plan covers eligible expenses at 100% for the remainder of
the calendar year.
Par – See BCBS Participating Provider
Plan Year – January 1 through December 31.
Post-Tax Contributions – Employee contributions for coverage under certain benefit plans that are deducted after federal and state income taxes and Social Security (FICA)
taxes are calculated and withheld.
POS (Point of Service) – A type of health plan that provides flexibility by allowing members to decide how to receive services each time services are needed. For
example, a member may choose to see a network or non-network provider each time he/she needs care. The highest level of benefits is generally obtained by using network
PPO (Preferred Provider Organization) – A group of doctors, hospitals, and other health care providers that contract on a fee-for-service basis to provide health care
services. Providers exchange discounted services for increased patient volume. Health plan members generally receive financial incentives -such as higher levels of
reimbursement -for using PPO providers.
Preferred Drug List – See formulary
Pre-Tax Contributions – Employee contributions for coverage under certain benefit plans that are deducted before federal and state income taxes and Social Security
(FICA) taxes are calculated and withheld.
Primary Care Physician (PCP) – The physician responsible for coordinating an HMO plan member’s health care. The PCP provides care and refers patients to specialists as
Qualifying Event – A specific change that allows an employee to make benefit election changes prior to the next open enrollment. The IRS refers to these changes as
“Qualified Family Status Changes”.
Salary – Basic pay, including paid vacation, paid holiday and paid sick time but excluding overtime pay, shift pay, bonuses and other compensation.
Waive Coverage – The enrollment option elected by an employee who is declining coverage under a benefit plan.