Simple definitions
Benefit
A service covered by your health insurance plan such as a doctor visit or X-ray.
Benefit booklet
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
- tools and programs to help you stay healthy and save money
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.
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.
Explanation of benefits (EOB)
See Healthcare services summary (HSS)
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
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.
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.
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
This is the most you would pay in one year before your health insurance starts to pay for all of your covered health benefits.
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.
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.
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.
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.
Summary of benefits
A quick summary of the key benefits of your plan.
Vaccination
A treatment that helps prevent illnesses like measles or the flu.
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