As you look at our plans or get a quote, you may see concepts and terms that are unfamiliar. To help you make smarter healthcare decisions, we've put together a list of common concepts and terms.
Once you have become a Blue Shield member, please refer to your Evidence of Coverage/Policy for the official definitions of these terms.
PPO: PPO stands for "Preferred Provider Organization." Blue Shield PPO plan members receive full coverage by using doctors and hospitals within the PPO network ("preferred providers"), but can also pay more to have the freedom to go outside of the network for care ("non-preferred providers").
HMO: HMO stands for "Health Maintenance Organization." An HMO provides comprehensive health care by network physicians to enrolled individuals and families in a particular geographic area. It is financed by fixed periodic payments determined in advance. In an HMO, you need to access care through a designated Personal Physician to receive coverage.
Personal physicians (applies to HMO plans): Providers who have contracted with Blue Shield to provide primary care to HMO members and to refer, authorize, supervise and coordinate the provision of all care to members.
Preferred providers (applies to PPO plans): Providers who have contracted with Blue Shield to be part of our preferred provider network. Preferred providers render covered services to PPO plan members at contracted rates (allowable amount). Except for applicable deductibles, copayments, coinsurance and amounts above the plan's benefit maximums, they will accept Blue Shield's payment as payment in full. Members under a Blue Shield Life plan access Blue Shield Life Preferred Providers.
Non-preferred providers (applies to PPO plans): Providers who have not contracted with Blue Shield (or Blue Shield Life as applicable) to be part of our preferred provider network. Non-preferred providers often charge members more than Blue Shield allowable amounts. You are responsible for the difference between the amount the non-preferred provider bills and any amount that Blue Shield pays. Some PPO plan benefits, such as certain preventive care and office visits, are not covered when accessed from these providers.
Deductible: The initial amount you pay in a calendar year for covered services before Blue Shield begins to pay.
Copayment: The fixed dollar and/or percentage amount you pay for covered services.
Copayment/coinsurance maximum: The dollar limit on the amount you may have to pay for many covered services in a calendar year. Once the maximum is reached Blue Shield will pay 100% of the allowable amount for all applicable covered services, up to specified maximums for the rest of the calendar year.
Coinsurance (applies to plans underwritten by Blue Shield Life): The percentage of the cost of a covered healthcare service you are responsible to pay after meeting any applicable plan deductible.
Pre-existing condition: An illness, injury or condition for which medical advice, diagnosis, care or treatment was recommended or received from a licensed health practitioner during the six months prior to the plan effective date.
Preventive care: Primary preventive medical services provided by a physician for the early detection of disease when no symptoms are present.
Waivered condition: A condition that is excluded from coverage for charges and expenses incurred six months from the effective date of coverage. A waivered condition only applies to a condition for which medical advice, diagnosis, care or treatment (including prescription drugs) was recommended or received from a licensed health practitioner during the six months immediately preceding the effective date of coverage.
Read our frequently asked questions about individual and family coverage.
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