Benefit Period

12 months from the original effective date.

Effective Date

Date which coverage for a member begins.

Creditable Coverage

Accepted health insurance coverage carried prior to the plans coverage.

Plan

The North Carolina Medical Society Employee Benefit Plan.

Plan Administrator

Medical Mutual Insurance Company of North Carolina - Discretionary authority and responsibility to manage and direct the operation of the plan.

Subscriber

Person eligible for coverage under the health benefit plan due to employment and who is enrolled.

Member

Employee or dependent currently enrolled in plan.

Dependents

Spouse or Domestic Partner and/or Child (biological, stepchild, adopted, foster or under your legal guardianship) to age of 26. Intellectually or physically disable, incapable of self-support may continue coverage regardless of age if the condition exists prior to turning 26 (Disability must be medically certified by the child's physician).

Copay

A copay is a flat fee that you pay on the spot each time you go to your doctor of fill a prescription. Example: If your copay is $25, every time you go you will pay that $25 copay. 

Deductible

The amount you pay for covered health care services before your insurance plan starts to pay. Example: If your deductible is $2,000 you are responsible for covering the first $2,000 dollars worth of covered services.

Coinsurance

Is a portion of the medical cost you pay after your deductible has been met. Example: If your coinsurance is 20%, you pay 20% of your medical expenses after you have reached your deductible. You will continue to pay that 20% until you have reached your out-of-pocket maximum.

Out-of-Pocket Max (OOPM)

The out-of-pocket maximum is the most you can will pay for covered medical expenses in a given plan year. Example: If you have a hospital bill for $100,000 your OOPM is $7,500 the most you will be obligated to pay is $7,500. deductible and coinsurance also apply, but you will not pay more than $7,500 during that plan year. 

Total Out-of-Pocket Limit

Maximum amount payable by the member in a benefit period before BCBS NC pays 100% of covered services.

Life Time Maximum

The benefit maximum of certain covered services, that will be reimbursed on behalf of a member while covered under the plan. Services in excess of lifetime maximum are not covered services and member is responsible for entire provider bill.

Allowed Amount

Maximum amount is the negotiated amount that a physician has agreed to accept as payment and considered reasonable for covered services provided to a member by the Blue Cross NC.

In-Network

Designated as participating in the Blue Options network.

In-Network Provider

Health care professional and facilities that are designated, contracted and participating providers.

Out-of-Network

Not designated as participating in the Blue Options network.

Out-of-Network Provider

Health care professional and facilities that are not designated, contracted and participting providers.

Waiting Period

Amount of time that must pass before a member is eligible to be covered for benefits under the terms of the plan.

Prior Authorization

Required to obtain before.

Incurred

Date on which member receives the service, drug, equipment or supply for which a charge is made.

Certification

Determination by BCBS NC that a service covered under the plan satisfies the requirements for medically necessary services.

Non-Certification

Adverse benefit determination by BCBS NC that a service covered under the plan was reviewed and does not meet the requirements for medical necessity.

Inpatient Care

Requires patient to be admitted and stay in a hospital overnight.

Outpatient Care

Is when a patient is seen and released from care without being admitted or having an overnight stay.

Medically Necessary

Covered services or supplies that are provided for or are necessary and appropriate to a diagnosis, treatment, cure or relief of a health condition (illness, injury or disease).

Preventive Care

Medical services provided that detect disease early in patients such as Immunizations, medications that delay or prevent disease, screenings and counseling services.

Investigational

Service or supply that BCBS NC does not recognize as standard medical care of a condition, disease, illness or injury.

Grievance

Dissatisfaction with any decisions, policies or actions related to availability, delivery or quality of health care services

Aggregate Deductible

The limit deductible a policyholder would be required to pay on claims during a given period of time.

Embedded Deductible

No single individual on a family plan will have to pay a deductible higher than the individual deductible amount.