B&C Chapter 13: BlueCross BlueShield

Question 1

Away From Home Care

Answer 1

provides continuous BCBS health care coverage for subscribers who will be located outside of their home service area for more than 90 consecutive days; subscribers are permitted access to participating providers in other areas of the United States.

Question 2

BCBS basic coverage

Answer 2

BlueCross BlueShield (BCBS) coverage for the following services: hospitalization, diagnostic laboratory services, x-rays, surgical fees, assistant surgeon fees, obstetric care, intensive care, newborn care, and chemotherapy for cancer.

Question 3

BCBS major medical (MM) coverage

Answer 3

provides patients with nationwide access to participating providers who offer a wide variety of health care services; reasonable out-of-pocket expenses, such as deductibles and coinsurance payments are included.

Question 4

BlueCard

Answer 4

program that allows BCBS subscribers to receive local Blue Plan health care benefits while traveling or living outside of their plan’s area.

Question 5

BlueCare Anywhere

Answer 5

allows members to have telehealth access to health care benefits for a number of non-urgent illnesses and injuries.

Question 6

BlueCross BlueShield (BCBS)

Answer 6

provides health plan coverage to Americans in all 50 states, the District of Columbia, and Puerto Rico; coverage is also provided to those who live, travel, and work internationally.

Question 7

BlueCross BlueShield Association (BCBSA)

Answer 7

independent, community-based, locally operated BlueCross BlueShield plans that collectively provide health care coverage to more than 100 million Americans.

Question 8

BlueCross BlueShield Global

Answer 8

international health care coverage for non U.S. based individuals who permanently reside outside the United States and provides health care coverage solutions during short- and long-term travel.

Question 9

coordinated home health and hospice care

Answer 9

allows patients with this option to elect an alternative to the acute care setting.

Question 10

Federal Employee Health Benefits Program (FEHBP)

Answer 10

an employer-sponsored health benefits program established by an act of Congress in 1959, which now provides benefits to more than 5 million federal enrollees and dependents.

Question 11

Federal Employee Program (FEP)

Answer 11

began covering federal employees in 1960, provides benefits to more than 5 million federal enrollees and dependents, and underwritten and administered by participating BlueCross BlueShield plans.

Question 12

for-profit corporation

Answer 12

pays taxes on profits generated by the corporation’s for-profit enterprises and pays dividends to shareholders on after-tax profits.

Question 13

GeoBlue

Answer 13

international health care coverage for employers, individuals, and students who are based in the United States and who are short-term travelers and long-term expatriates.

Question 14

Government-Wide Service Benefit Plan

Answer 14

phrase printed below the BCBS trademark on federal employee plan (FEP) insurance cards, which indicates that the enrollee has federal employer-sponsored health benefits.

Question 15

Health Care Anywhere

Answer 15

concept that allows members of independently owned and operated health plans to have access to health care benefits throughout the United States and around the world.

Question 16

indemnity coverage

Answer 16

offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed health care provider.

Question 17

medical emergency care rider

Answer 17

covers immediate treatment sought and received for sudden, severe, and unexpected conditions that, if not treated, would place the patient’s health in permanent jeopardy or cause permanent impairment or dysfunction of an organ or body party.

Question 18

member

Answer 18

subscribers

Question 19

members hospital

Answer 19

hospital that has signed a contract to provide services for special rates.

Question 20

nonprofit corporation

Answer 20

charitable, educational, civic, or humanitarian organization whose profits are returned to the program of the corporation rather than distributed to shareholders and officers of the corporation.

Question 21

outpatient pretreatment authorization plan (OPAP)

Answer 21

also called prospective authorization or precertification; requires preauthorization of outpatient physical, occupational, and speech therapy services.

Question 22

PPN provider

Answer 22

provider who has signed a preferred provider network (PPN) contract and agrees to accept the PPN allowed rate, which is generally 10 percent lower than the PAR allowed rate.

Question 23

preferred provider network (PPN)

Answer 23

program that requires providers to adhere to managed care provision.

Question 24

prepaid health plan

Answer 24

contract between employer and health care facility (or physician) where specified medical services were performed for a predetermined fee that was paid on either a monthly or yearly basis.

Question 25

prospective authorization

Answer 25

see outpatient pretreatment authorization plan (OPAP).

Question 26

rider

Answer 26

special contract clause stipulating additional coverage above the standard contract.

Question 27

service location

Answer 27

location where the patient was seen

Question 28

special accident injury rider

Answer 28

covers 100 percent of nonsurgical care sought and rendered within 24 to 72 hours (varies according to policy) of the accidental injury.

Question 29

usual, customary, and reasonable (UCR)

Answer 29

description of amount commonly charges for a particular medical service by providers within a particular geographic region; used for establishing allowable rates.