Annual Copayment Maximum: The most you’ll pay out of your pocket in copayments for in-network services you receive during the year. Once you reach the annual copayment maximum, the plan pays 100% of the cost for in-network services for the rest of the year.
Blue Distinction Centers+: Blue Cross-designated outpatient surgical centers specializing in knee and hip replacement. Blue Distinction Centers+ meet high standards of quality, cost, expertise, effectiveness, and efficiency.
Coinsurance: The percentage of eligible costs that you pay for services, after the deductible has been paid.
Copayment: The flat dollar amount you pay for some medical services at the time you receive care.
Deductible: The portion of your covered expenses that you pay each year before you medical plan begins to pay benefits for specified services.
In-Network Providers: A select group of providers and facilities that agreed to charge negotiated fees for their services. When you use these providers, you’re receiving “in-network care.”
Medically Necessary Expenses: Services covered by the plan if they’re considered appropriate. Some services and supplies aren’t covered at all, while benefits for other services (such as chiropractic care) are limited. In addition, the expense must be incurred while the patient is covered under the plan, unless specifically provided otherwise.
Out-of-Network Providers: A doctor, other professional provider or durable medical equipment, home health care or home infusion supplier who is not in the Plan’s network for hospital, medical, mental health and substance abuse, pharmacy, vision or dental benefits and does not have a contract with the insurance carrier. Out-of-network benefits are benefits for covered services provided by out-of-network providers and suppliers.
Patient-Centered Medical Home (PCMH): An office or group of doctors who work together to coordinate and personalize your care. Getting care at a PCMH and selecting a PCMH doctor as your primary care physician saves you money.
Plan Allowance: The amount the plan pays for a specific medical service in a designated geographic area. You’re responsible for charges above the plan allowance if you don’t use a network provider under the High Option Plan (Phlex Plan only).
Primary Care Physician (PCP): Also referred to as the “family doctor,” PCPs are your first contact when you have a health concern. Your PCP also provides continuing care and referrals to specialists as needed. Keystone has designated certain doctors as PCPs; you must consult your Keystone Physician Directory to select an eligible PCP.
Self-Referred Care: Care you receive from a doctor who is not your PCP, or without a referral from your PCP. This is the most expensive way to receive care. For self-referred care, the plan generally pays 70% of the plan allowance after you meet the annual deductible.