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  • Protecting Retiree Benefits
  • Supporting SRS Missions

Glossary of
Medical Insurance
Terms

Glossary of terms used during health care claims processing
 
For additional Medicare terms see http://www.medicare.gov/Glossary/
 
Term Definition
ACTUAL CHARGE The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount Medicare approves. (See Approved Amount; Assignment.)
AMOUNT APPROVED FOR COORDINATION (BCBS)
 
The amount Blue Cross/Blue Shield will coordinate with your primary health or dental plan's payment.
APPROVED AMOUNT
 (also called Allowable Amount)
The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by you and Medicare for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the "Approved Charge." (See Actual Charge; Assignment.)
ASSIGNMENT In the Original Medicare Plan, this means a doctor agrees to accept the Medicare-approved amount as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor's visit.
BENEFIT PERIOD The way that MEDICARE measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven't received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins if you are in the Original Medicare Plan. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

FOR BLUE CROSS/BLUE SHIELD, the Benefit Period is the period of time you must pay any deductibles and coinsurance payments that may apply. Benefits begin once you meet the deductible. If you reach the limit, we pay covered expenses in full for the rest of the benefit period. Deductibles and coinsurance start over with each new benefit period.
CARVE OUT With the carve-out provision of the SRS Plan, the Medicare payment is carved-out (or subtracted) from the SRS payment, rather than the SRS payment being calculated as a supplement to the Medicare payment. Therefore, to calculate the SRS Plan secondary payment, BCBSSC has to: (1) determine what would be payable if the SRS Plan were primary; and then, (2) subtract the amount payable under Medicare.

If the result of the SRS primary payment minus the Medicare payable amount is positive, then BCBSSC will make a secondary payment under the SRS plan (to the lesser of the Medicare Allowable Amount or the SRS primary payment).  However, if the result of the SRS primary payment minus Medicare is equal to $0 or a negative amount, then there will be no secondary payment from the SRS Plan.
COINSURANCE The percentage of the Medicare payment rate or a hospital's billed charge that you have to pay after you pay the deductible for Medicare Part B services.

For BLUE CROSS/BLUE SHIELD, Coinsurance is the percentage of the allowed amount you pay as your share of the bill. If your plan pays 80%, then 20% would be your coinsurance.
COORDINATION OF BENEFITS Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim.
CO-PAYMENT
(CO-PAY)
A fixed amount that you pay per visit depending on your health choice plan
COST SHARING The cost for medical care that you pay yourself like a co-payment, coinsurance, or deductible. (See Coinsurance; Co-payment; Deductible.)
DEDUCTIBLE
(BCBS)
The amount, if any, that you are responsible for paying before BCBS starts paying contract benefits. You do not send this amount to BCBS. BCBS subtracts this amount from covered expenses on the claims you and health care professionals send to BCBS.
DEDUCTIBLE
(MEDICARE)
The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. (See Benefit Period; Medicare Part A; Medicare Part B.)
EXCESS CHARGES If you are in the Original Medicare Plan, this is the difference between a doctor's or other health care provider's actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.
EXCLUSIONS
(MEDICARE)
Items or services that Medicare does not cover, such as most prescription drugs, long-term care, and custodial care in a nursing or private home.
FEE SCHEDULE A complete listing of fees used by health plans to pay doctors or other providers.
GAPS The costs or services that are not covered under the Original Medicare Plan.
LESS BENEFIT LIMITATION (BCBS) The amount that is more than your contract allows for this type of service. Your plan covers these services until you have reached the limit of your benefits.
LIFETIME RESERVE DAYS In the Original Medicare Plan, 60 days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance .
LIMITING CHARGE In the Original Medicare Plan, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don't accept assignment. The limiting charge is 15% over Medicare's approved amount. The limiting charge only applies to certain services and doesn't apply to supplies or equipment.
MAXIMUM ENROLLEE OUT-OF-POCKET COSTS The beneficiary's maximum dollar liability amount for a specified period.
MAXIMUM PLAN BENEFIT COVERAGE The maximum dollar amount per period that a plan will insure. This is only applicable for service categories where there are enhanced benefits being offered by the plan, because Medicare coverage does not allow a Maximum Plan Benefit Coverage expenditure limit.
MEDICARE BENEFITS Health insurance available under Medicare Part A and Part B through the traditional fee-for service payment system.
MEDICARE PART A (HOSPITAL INSURANCE) Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
MEDICARE PART B (MEDICAL INSURANCE) Medicare medical insurance that helps pay doctors' services, outpatient hospital care, durable medical equipment, and some medical services that aren't covered by Part A.
MEDICARE
SUMMARY
NOTICE (MSN)
A notice you get after the doctor or provider files a claim for Part A and Part B services in the Original Medicare Plan. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.
MEDICARE-APPROVED
AMOUNT
In the Original Medicare Plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare and you for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the 'Approved Charge.'
NETWORK
PARTICIPATION
(BCBS)
This column of your EOB statement shows whether or not the health care professional who provided the service participates in our network. If "YES", this is a network participant. If "NO", this is not a network participant. If "N/A", the issue doesn't apply to your coverage, or to this particular claim.
ORIGINAL
MEDICARE
PLAN
A pay-per-visit health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
OUT-OF-POCKET COSTS Health care costs that you must pay on your own because they are not covered by Medicare or other insurance.
OUT-OF-POCKET MAXIMUM
(BCBS)
The highest amount of the covered expenses you will have to pay during a benefit period.
PARTICIPATING PHYSICIAN OR SUPPLIER A doctor or supplier who agrees to accept assignment on all Medicare claims. These doctors or suppliers may bill you only for Medicare deductible and/or coinsurance amounts. (See Assignment.)
PRIMARY PAYER An insurance policy, plan, or program that pays first on a claim for medical care. This could be Medicare or other health insurance.
PRIVATE CONTRACT A contract between you and a doctor, podiatrist, dentist, or optometrist who has decided not to offer services through the Medicare program. This doctor can't bill Medicare for any service or supplies given to you and all his/her other Medicare patients for at least 2 years. There are no limits on what you can be charged for services under a private contract. You must pay the full amount of the bill.
SECONDARY PAYER An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.
TOTAL BENEFIT ALLOWED
(BCBS)
The amount BCBS would have paid if another insurance carrier were not involved.
UNASSIGNED CLAIM A claim submitted for a service or supply by a provider who does not accept assignment.



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SRS Retiree Association, Inc.
Aiken SC

Revised: January 2, 2015


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