annual deductible
The amount you are required to pay annually before reimbursement by your health care benefits plan begins.

annual out-of-pocket maximum
The maximum amount, per year, you are required to pay out of your own pocket for covered health care services. The annual out-of-pocket amount may or may not include a deductible.

calendar year maximum
A form you may have to fill out and submit to your health insurance carrier for payment of benefits under that health care plan.

claim
An itemized bill for services that have been provided to a subscriber, a subscriber's spouse or dependents.

claim form
A form you may have to fill out and submit to your health insurance carrier for payment of benefits under that health care plan.

COBRA
A federal act (Consolidated Omnibus Budget Reconciliation Act of 1985) which requires group health care plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event which causes the loss of group health coverage. Qualifying events include reduced work hours, termination of employment, a child becoming and over-aged dependent, Medicare eligibility, death or divorce of a covered employee.

coinsurance
A percentage of a covered charge that you are required to pay toward a service covered by your plan. Not all plans require coinsurance.

Coordination of Benefits (COB)
An arrangement where, if you or your dependents are covered under more than one health care plan, the plans work together to coordinate reimbursement for benefits you receive.

copayment
A fixed dollar amount you are required to pay for a service at the time you receive care. Not all plans require copayments.

covered service
A service that is covered by your health care plan.

deductible
A fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins.

dependent
A person, other than the subscriber (generally a spouse or child), who receives health care coverage under the subscriber's health care plan.

domestic partner
A person with whom the member has entered into a long-term, committed relationship. The relationship must meet the health care plan's specific criteria for a domestic partnership.

drug list
A list of commonly prescribed drugs (also known as a prescription drug formulary). Not all drugs on a plan's prescription drug list are automatically covered under that plan.

enrollment date
The first day of coverage or, if your group has a waiting period prior to coverage, the first day of the waiting period (for example, the date your employment begins).

Explanation of Benefits (EOB)
The form sent to you after a claim payment has been processed by your health care plan. The EOB explains the actions taken on the claim such as the amount that will be paid, the benefit available, reasons for denying payment and the claims appeal process.

exclusions
Specific medical conditions, procedures or circumstances that are not covered under a health care plan.

family coverage
Health care coverage for a member and his or her eligible dependents.

formulary
A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.

generic drug
A prescription drug that is the generic equivalent of a brand-name drug listed on your health plan's drug list (formulary).

generic substitute
A prescription drug which is the generic equivalent of a drug listed on your health plans formulary.

group
A group of people covered under the same health care plan and identified by their relation to the same employer.

Health Maintenance Organization (HMO)
An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers.

HIPAA
A federal law which outlines certain rules and requirements employer-sponsored group health plans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups; most recently amended to add privacy rules which became effective April 14, 2003.

individual coverage
Health care coverage purchased by a person for him/herself that may include coverage for dependent(s).

individual lifetime maximum
The maximum amount of benefits your plan will pay over the course of your lifetime.

in-network
Covered services provided or ordered by your primary care physician (PCP) or another provider referred by a your primary care physician.

inpatient services
Services provided when a member is registered as a bed patient and is treated as such in a hospital or other health care facility.

maximum allowance
A fixed amount that doctors and hospitals agree to accept as payment in full for a particular covered service.

maximum annual benefit
The maximum dollar amount your health care plan will pay for all health care services provided to you during one year.

Medicaid
A joint federal and state funded program that provides health care coverage for low-income children and families, and for certain aged and disabled individuals.

medical group
A licensed health care facility, program, agency, doctor or health professional that contracts with a health plan to deliver health care services to plan members.

Medicare
The federal program established to provide health care coverage for eligible senior citizens.

Medicare Part A
The federal program established to provide health care coverage for eligible senior citizens. Medicare Part A provides basic hospital insurance coverage automatically for most eligible persons.

Medicare Part B
The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part B provides benefits to help cover the costs of doctors' services.

Medicare Part C
The federal program established to provide health care coverage for eligible senior citizens. Medicare Part B provides benefits to cover the costs of doctors' services.

member
Any individual who receives health care coverage from Blue Cross and Blue Shield of New Mexico.

network
The group of doctors, hospitals and other medical care professionals that a health care plan has contracted with to deliver medical services to its members.

non-participating provider
A provider (hospital, doctor, or other health care professional or facility) that does not have an agreement with a particular health care plan to provide services to members in that plan.

non-preferred providers
A non-preferred provider does not have a preferred or PPO contract with Blue Cross and Blue Shield of New Mexico. For most benefits, after you've met the non-preferred provider deductible, you will pay a percentage of covered charges for services you receive from non-preferred providers.

out-of-network
Services not provided or ordered by your primary care physician (PCP) or upon referral of your primary care physician.

out-of-pocket maximum
The maximum amount you have to pay for most or all expenses covered under your health care plan during a defined benefit period.

outpatient services
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

participating hospital
A hospital that has an agreement with a particular health care plan to provide hospital services to members of that plan.

participating provider
A provider (hospital, doctor, or other health care professional or facility) that has an agreement with a particular health care plan to provide services to members of that plan.

pre-certification
The process by which a plan member or their primary care physician (PCP) notifies the plan, in advance, of plans for the member to undergo a course of care such as a hospital admission or a complex diagnostic test.

pre-existing condition
A health condition for which an individual received medical care during the time prior to his/her effective date of coverage.

preferred provider
A health care professional or a facility that has a preferred or PPO contract with Blue Cross and Blue Shield of New Mexico or another Blue Cross and Blue Shield Plan.

Preferred Provider Organization (PPO)
A health care plan that supplies services at a discounted cost for members who use designated health care providers. PPOs usually provide coverage for services rendered by health care providers who are not part of the PPO network, however the member generally shares a greater portion of the cost for such services.

preferred drug list
A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a health plan's prescription drug list are automatically covered under that plan.

prescription drugs
Drugs and medications that, by law, must be dispensed by a written prescription from a licensed doctor.

prescription drug list
A list of commonly prescribed drugs (also known as a drug formulary). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.

preventive care
Care that focuses on the prevention of disease (e.g., immunizations, routine well baby care, routine physical exams, and vision and hearing examinations).

primary care physician (PCP)
The physician you choose to be your primary source for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Not all health plans require a PCP or referrals.

prior approval
The process by which a plan member or his or her primary care physician (PCP) notifies the plan, in advance, of plans for the member to undergo a course of care, such as a hospital admission or a complex diagnostic test.

provider
A duly licensed hospital, program, doctor or other medical professional or facility authorized to deliver health care services.

prior authorization
The process by which a plan member or his or her primary care physician (PCP) notifies the plan, in advance, of plans for the member to undergo a course of care, such as a hospital admission or a complex diagnostic test.

referral
A primary care physician's (PCP) recommendation that a patient see a specific specialist for further treatment. A referral number is assigned and may have a specific number of days, units of treatment, and an expiration date. Not all plans require referrals.

specialist
A health care professional whose practice is limited to a certain branch of medicine such as specific procedures, age categories of patients, specific body systems or certain types of diseases.

urgent care
Situations that are not life threatening (that is, are not medical emergencies), but require prompt medical attention or urgent care. Examples of conditions that are considered urgent are sprains, high fever, and cuts requiring stitches.