Important terms

Click any letter below to view important terms and definitions. If the letter is “grayed out,” there are currently no definitions in our glossary that begin with that letter.

A

Allowed benefit — the fee that providers in the CareFirst BlueCross BlueShield network have agreed to accept for a particular medical service. CareFirst has negotiated very favorable discounts on medical services for our members. If you see a doctor who is not in your plan’s network who charges more, the difference is your responsibility.

B

Balance billing — is when the provider charges you the difference between their billed amount and the CareFirst allowed benefit. It is important to know that providers who participate in your CareFirst plan’s network have agreed to accept the allowed benefit as payment in full.

C

Cost-sharing — the portion of your healthcare costs that your plan doesn’t pay is your share. Generally, the more costs you’re willing to pay, the lower your monthly premiums. The less cost-sharing you want to be responsible for, the higher your premium will be. Cost-sharing is different from your premium. It’s made up of three parts: deductible, copayment and coinsurance.

  • Deductible — the amount of money you must pay each calendar year before a plan begins paying its portion of your costs. Meeting your in-network deductible of $1,500, for example, means you’ll pay the first $1,500 for in-network healthcare services covered by your plan, and then CareFirst will start paying for part or all of the services after that. Only costs based on CareFirst’s allowed benefit amount will count toward your deductible. For plans with out-of-network benefits, the out-of-network deductible will accumulate separately for out-of-network services.

    Look closely at the plan options you are considering. All of them offer no charge preventive care that is not subject to a deductible. Some even cover all primary care visits, urgent care and drugs without needing to meet a deductible first.

  • Copay/Copayment — is a fixed dollar amount that you pay when you visit a provider, like $25 when you visit a doctor or $200 for a trip to the emergency room. Depending on the plan, you may pay copays before or after you meet your deductible.

  • Coinsurance — is the percentage you pay of the allowed benefit amount after you’ve met your deductible. So if the allowed benefit amount is $100, and your plan has 20% coinsurance, you would pay $20 and CareFirst would pay the remaining $80. Many of our top plans do not include coinsurance when you stay within network. However, specialty drugs typically do require coinsurance.

D

Deductible, aggregate (for family coverage only) — the family deductible must be met before the plan starts to pay toward services for any one member. The deductible may be met by one member or any combination of members. Please note that this is product specific and is indicated on the benefit summaries.

Deductible, integrated — a type of deductible where both prescription drug and medical expenses contribute toward the deductible.

Deductible, non-integrated — only medical claims accumulate to the medical deductible and prescription drug claims accumulate to the prescription drug deductible.

Deductible, separate (for family coverage only) — when one family member meets the individual deductible, their services will be covered at 100% up to the allowed benefit. Each family member cannot contribute more than the individual deductible amount. The family deductible must be met before the services for all remaining family members will be covered at 100%, up to the allowed benefit. Please note that this is product specific and is indicated on the benefit summaries.

DC Health Link — an online marketplace created for individuals, families, small business owners and their employees in the District of Columbia to shop, compare and select health insurance that meets their health needs and budgets.

E
F

Facility charge — if a service is rendered on a hospital campus, you may receive two bills, one from the physician and one from the facility. It is your responsibility to determine if they will be billed separately.

Formulary — a list of covered prescription drugs. Our drug list is reviewed and approved by an independent national committee comprised of physicians, pharmacists and other healthcare professionals who make sure the drugs on the formulary are safe and clinically effective. The prescription drugs found on the CareFirst formulary (drug list) are divided into tiers. These tiers include no cost drugs, generics, preferred brand, non-preferred brand, preferred brand specialty, and non-preferred brand specialty drugs. Your cost-share is determined by the tier the drug falls into.

G
H

HSA-compatible plans — can help lower your healthcare costs. HSA stands for Health Savings Account, a tax-exempt account that works like an IRA for health expenses. Within your plan choices, CareFirst BlueCross BlueShield offers HSA-compatible plans that can help lower healthcare costs for high-deductible, lower premium plans. By contributing tax-exempt money (usually the money you save on lower premiums), you build up savings in your HSA that can be used to pay for eligible medical expenses for you, your spouse and your dependents—even if they are not enrolled in your medical plans.

I

In network — refers to the use of providers who participate in the health plan’s provider network. Using participating in-network providers gives you a higher level of coverage, meaning you have lower out-of-pocket expenses and a lower in-network deductible.

J
K
L
M

Mandatory generic substitution — if your provider prescribes a non-preferred brand-name drug and you get a non-preferred brand-name drug when a generic is available, you will pay the non-preferred brand copay or coinsurance PLUS the difference between the generic and non-preferred brand-name drug cost up to the cost of the prescription.

N

National plans — National plans have access to a large network of providers throughout the country. National plans are recommended for members who work and reside outside the CareFirst service area of Maryland, Washington, D.C. and Northern Virginia.

O

Out of network — the use of healthcare providers who have not contracted with CareFirst to provide services. Health Management Organization (HMO) members are generally not covered for out-of-network services except in emergency situations. Members enrolled in Point of Service (POS) and Preferred Provider Organization (PPO) plans can go out of network, but will pay higher out-of-pocket costs.

Out-of-pocket maximum — is the most you will have to pay in deductibles, copays, coinsurance and prescription drug costs in a calendar year. After that, CareFirst will pay 100% of the allowed benefit amount for covered services—except for your premiums—for the rest of that year. For plans with in-network and out-of-network benefits, the deductible will accumulate separately for the in-network and out-of-network services.

P

Premium — the money you pay each month for your plan, or policy, is your premium. Premiums are based on your age, the family members the plan will cover, and how much of your healthcare costs your employer pays.

Prescription drugs/devices — a written order or refill notice issued by a licensed medical professional for drugs or devices (e.g., syringes, needles for diabetics) that are only available through a pharmacy.

Q
R

Regional plans — Regional plans use the BlueChoice network of participating doctors, specialists and hospitals only available in Washington, D.C., Maryland and Northern Virginia for in-network coverage. This geographic area is also called the CareFirst service area. Regional plans are not recommended if you live or work outside the CareFirst service area.

S

Service area — the geographic area in which a health plan delivers healthcare through a contracted network of participating providers. The CareFirst regional plans service area includes Washington D.C., Maryland and Northern Virginia. National plans will have coverage across the country.

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X
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