Simple definitions
Benefit
A service covered by your health insurance plan such as a doctor visit or X-ray.
Case management (also known as care coordination)
A process of coordinating care between your insurer and your healthcare providers to help manage your health. Case managers are often nurses, dietitians, and social workers. Learn more
Chronic condition
A long-term illness that affects your quality of life, such as diabetes, asthma, heart disease, and arthritis. Learn more
Claim
The bill that a doctor sends to your health insurance company after they treat you. In some cases, members may submit claims for reimbursement.
Coinsurance
A portion of the cost you pay when you get healthcare.
Example: A doctor might charge $100 for a visit. If your health insurance has a 10% coinsurance, you would pay the doctor $10 and your insurance would pay the doctor $90.
Copay
A specific dollar amount you pay when you get healthcare.
Example: A doctor might charge $100 for a visit. If your health insurance has a $20 copay, you would pay the doctor $20 and your insurance would pay the doctor $80.
Consumer-directed health plans (CDHPs)
These plans generally have higher deductibles in exchange for lower premiums and the ability to open a health savings account, which could save you money on taxes. These plans are sometimes called high-deductible health plans.
Deductible
If you need medical care, a deductible is the amount you pay for your care before the health insurance company starts to pay its share.
Durable medical equipment
Equipment and supplies ordered by a healthcare provider for everyday or extended use, such as oxygen equipment, wheelchairs, or crutches.
Essential health benefits
A set of healthcare service categories that must be covered by certain plans, according to the federal Affordable Care Act. These include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Explanation of benefits (EOB)
See Healthcare services summary (HSS)
Flexible spending arrangement (FSA)
An account set up through an employer to pay for many out-of-pocket medical expenses with tax-free dollars. These expenses include copays, deductibles, qualified prescription drugs, insulin, and medical devices. FSA accounts also can be set up for childcare, parking, and commuting costs. Learn more
Formulary
The list of prescription drugs that are covered by your health insurance. These are often divided into levels, or tiers. Drugs listed in the lower tiers generally cost you less.
Health reimbursement account (HRA)
An employer-funded plan from which you are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Learn more
Health savings account (HSA)
A financial account where you can set aside money for medical expenses. Putting money into your account may reduce your taxes, and you can use the account to pay your medical expenses. Learn more
Healthcare services summary (HSS)
Also called an explanation of benefits (EOB), this is a statement of your benefits and coverage that you receive that says clearly, “This is not a bill.” You receive it when you are responsible for paying a share of the claim that a doctor submitted to BCBSRI. It explains whether the service is covered, how much was paid, and how much you owe. The HSS is not a bill. Once you receive the actual bill from your doctor, you should compare the amounts on each. They should be the same. Learn more
HealthSource RI
A health insurance marketplace (also called an exchange) set up by the state of Rhode Island. Through HealthSource RI, individuals, families, and small businesses can learn about their health coverage options, compare health insurance plans based on costs, benefits, and other important features, choose a plan, and enroll in coverage.
Health maintenance organization (HMO)
An organization that provides healthcare coverage to its members through a network of doctors, hospitals, and other healthcare providers. HMO plans usually require that all of a member’s care, including their annual exam, any diagnostic tests, and referrals to specialists be coordinated through the member’s primary care provider (PCP).
Hospital readmissions
A situation where you were discharged from the hospital and wind up going back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, since it could mean that your follow-up care wasn't properly organized or that you weren't fully treated the first time.
Mail order drugs
Prescription drugs that you can order by phone or online and have them delivered to your door. BCBSRI members may have a lower copay for a 90-day supply of many common medications. Learn more
Medicaid
A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults.
MedsYourWay®
A prescription savings program—no coupons or discount cards needed—and all covered prescription purchases count toward your deductible (if applicable) and out-of-pocket maximum.*
Network
A group of hospitals, pharmacies, doctors, and others who sign contracts with your health insurance company to provide you with healthcare. They have agreed to care for you at a lower price than if you didn’t have your health insurance plan. Different plans can have different networks of providers. Learn more
Out-of-network
Services provided by doctors, hospitals, and other healthcare providers who have not contracted with the insurance company. These services may have different copays or coinsurance than in-network services, or they may not be covered at all (meaning that the member is responsible for the full cost of the services).
Out-of-pocket maximum
The maximum amount you would pay out-of-pocket for covered healthcare services each year, including deductible, copays, and coinsurance. After the out-of-pocket is met, in-network covered services are paid at 100% by Blue Cross & Blue Shield of Rhode Island.
Over-the-counter (OTC)
Medicine or another healthcare item, such as bandages, that you can buy without a prescription.
Patient-centered medical home (PCMH)
A type of doctor’s office with a team of people committed to improving your health and helping you live a healthier lifestyle. They often are open longer hours. Your PCMH team can help you achieve your health goals. For example, they might help you quit smoking, control your diabetes or asthma, lose weight, or manage your stress.
Point of service (POS)
POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care provider who will then make referrals to specialists in the plan's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, or may not be covered at all (you may be responsible for the full cost).
Preferred provider organization (PPO)
A type of health plan with a preferred network of doctors and other healthcare providers. Members usually do not have to get referrals for specialty or out-of-network care, but they may have higher out-of-pocket costs for out-of-network care. In some plans, out-of-network care may not be covered.
Premium
The amount of money your employer pays to your health insurance company for coverage under your health insurance plan. You may pay part of that cost to your employer in each pay period.
Prescription
An order from your doctor for you to receive and take a specific medication. You then get your medication by having your prescription filled at a pharmacy.
Preventive care
Steps you and your doctor take to help you stay healthy, even when you feel well. They might include your annual checkup or screenings for certain diseases, including diabetes, cancer, and others.
Primary care provider (PCP)
The main doctor, nurse practitioner, or physician’s assistant you go to for regular healthcare. Your PCP is your partner in health. They know your health history and help you get the best care. Learn more
Provider directory
A comprehensive list of the providers in the BCBCRI networks.
Referral
An order from your primary care provider (PCP) for you to receive care from another doctor, specialist, or medical facility. Learn more
Rehabilitation services (rehab)
Healthcare services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical, occupational, and speech therapy services in a variety of inpatient and/or outpatient settings.
Screening
A test, such as a mammogram or colonoscopy, that can help find a health problem early, before it gets worse.
Special enrollment period
If you have a significant life event, such as losing your coverage or moving to an area no longer covered by your insurance company, you may be eligible to change your plan during a special enrollment period.
Specialist
A doctor who has special training in treating a certain illness or part of the body. Your primary care provider (PCP) may suggest you see a specialist if you have a specific health problem. For example, a cardiologist treats the heart and an oncologist treats cancer.
Specialty drugs
Medicine that is prescribed to treat chronic or long-term conditions, such as infertility, HIV, cancer, multiple sclerosis, and others. These drugs may require special monitoring by a doctor to reduce health risks and watch for side effects.
Subscriber agreement
A document that provides information about your plan, including:
- how your health coverage works;
- how BCBSRI processes claims for the health services you receive;
- your rights and responsibilities as a BCBSRI member;
- BCBSRI’s rights and responsibilities; and
- tools and programs to help you stay healthy and save money
Summary of benefits
A quick summary of the key benefits of your plan.
The Rhode Ahead
A BCBSRI member newsletter with plan updates, health tips, recipes, and ideas for active, healthy lifestyles. Learn more
Vaccination
A treatment that helps prevent illnesses like measles or the flu.
Virgin Pulse®
A company headquartered in Rhode Island that powers the BCBSRI wellness program with an app or web-based tool for tracking steps, joining challenges with friends, and learning healthy habits. Virgin Pulse is an independent wellness company, contracted by BCBSRI to provide wellness services.
Waiting period
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage. BCBSRI only has waiting periods in its dental plans.
Wellness program
A program intended to improve and promote health, fitness, and overall well-being. BCBSRI programs are powered by Virgin Pulse® technology and offer the ability to track your activities, friendly competitions, and incentives to participate. BCBSRI wellness programs also address smoking, diabetes management, weight loss, and preventive health screenings. Learn more
Your Blue Store
Locations where you can talk to our customer service team face-to-face, pay bills, take exercise classes like yoga and salsa, and attend seminars on health, nutrition, and other topics. Learn more
*MedsYourWay is not insurance. It is a drug discount program administered by Prime Therapeutics, LLC, an independent company contracted by BCBSRI to provide pharmacy benefit management services. Ask your pharmacy if they participate in MedsYourWay before filling your prescription.