Terms and definitions
Allowed or allowable amount (negotiated rate)
The allowable amount is the fee providers charge for medical services. Blue Shield of California negotiates these fees directly with the provider to offer you a lower rate as part of your health plan. Only our network providers will accept our negotiated rate as payment in full (does not include deductibles, copayments, and coinsurance).
Benefits or covered services
Benefits are medically necessary services and supplies covered by your health plan.
Claim
A claim is a notice submitted to Blue Shield requesting payment for services that you received under the terms of your health plan contract.
Coinsurance
Coinsurance is the percentage amount that you pay for benefits after you meet any applicable calendar-year deductible.
Copayment (or copay)
A copay is a set dollar amount you pay for covered services after you meet any applicable deductible.
Covered services
Cost-sharing reduction
Cost-sharing reduction is a discount that lowers the amount you have to pay for out-of-pocket costs including deductibles, coinsurance, and copayments. This discount is available to individuals and families with incomes up to 250% of the federal poverty level. Health plans with a cost-sharing reduction are only available through Covered California.
Deductible
A deductible is the amount you pay each calendar year for most covered services before Blue Shield begins to pay. Specific services, such as preventive care, are covered 100% before you reach the calendar-year deductible if you see a provider in your network.
Negotiated rate (allowed or allowable amount)
See Allowed or allowable amount
Network or provider network
A network is a group of providers, which includes doctors and hospitals, that has a contract with Blue Shield to provide covered services to you.
Note: A network provider can also be referred to as a participating provider.
Non-network provider or non-participating provider
A non-network provider is one that does not have a contract with Blue Shield to provide you covered services. If you choose to use a doctor or hospital that is not in your plan's network, this will likely increase your costs; or, if the service isn’t covered, you will be responsible for all billed charges.
Note: A non-network provider can also be referred to as a non-participating provider.
Out-of-pocket expense
An out-of-pocket expense is an expense you pay that Blue Shield will not reimburse you for. Out-of-pocket expenses toward covered services can include deductibles, copayments, or coinsurance, but they can also include costs for non-covered services or charges above the allowable amount.
Out-of-pocket maximum
Your out-of-pocket maximum is the most that you would have to pay in one year toward deductible, copay, and coinsurance amounts for covered services. After you reach your out-of-pocket maximum, your health plan will pay 100% of eligible benefits covered by your plan.
Premium
The premium is the amount you pay each month for health coverage.
Premium help
Premium help is financial help provided through government payments. Payments are made directly to your health insurance plan to lower the cost of your monthly premiums. The amount is based on an estimate made when you enroll. Premium help can be provided through a federal tax credit, also known as Advanced Premium Tax Credit (APTC) and is only available for plans bought through Covered California.
Provider
A provider includes healthcare and mental health professionals and facilities, such as physicians, hospitals, skilled nursing facilities, medical equipment suppliers, laboratories, pharmacies, physical therapists, clinical psychologists, or licensed marriage and family therapists.
For more helpful definitions, see Centers for Medicare and Medicaid Services glossary.
