The Blue Cross Blue Shield Association is an association of 36 independent, locally operated Blue Cross and/or Blue Shield companies.

A

accountable care organization (ACO)

A group of healthcare providers that agrees to deliver coordinated care, meeting performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations.

Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act (commonly called the ACA) was signed into law in 2010 to address access, quality and cost in the healthcare industry. The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” refers to the final, amended version of the law.

ambulatory care facility (ACF)

A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery and outpatient care, in a centralized facility.

ASC – Ambulatory Surgery/Surgical Center

A free-standing center that performs various types of surgery.

C

coordinated care plans (CCP)

The Medicare+Choice delivery option that includes health maintenance organizations, or HMOs (with or without a point-of-service component), preferred provider organizations (PPOs) and provider-sponsored organizations (PSOs).

D

dental health maintenance organization (DHMO)

An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment. For all of your dental questions and/or claim forms, please contact your local Blue Cross Blue Shield company.

dental point of service (dental POS) option

A dental service plan that allows a member to use either a dental health maintenance organizations (DHMO) network dentist or to seek care from a dentist not in the health maintenance organization's (HMO) network. Members choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care. For all of your dental questions and/or claim forms, please contact your local Blue Cross Blue Shield company.

dental preferred provider organization (dental PPO)

An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members. For all of your dental questions and/or claim forms, please contact your local Blue Cross Blue Shield company.

drug utilization review (DUR)

A review program that evaluates whether drugs are being used safely, effectively and appropriately.

E

electronic medical record (EMR)

A computerized record of a patient's clinical, demographic and administrative data. Also known as a computer-based patient record.

F

Federal Employee Health Benefits Program (FEHBP)

A voluntary health insurance program for federal employees, retirees and their dependents and survivors.

Flexible Spending Account (FSA)

Allows members to use pre-tax dollars for certain eligible medical and dependent care expenses. Members fund their FSAs with contributions that come out of their paycheck.

H

health maintenance organization (HMO)

A healthcare system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.

Health Reimbursement Arrangements (HRA)

Accounts that employers can establish for employees to reimburse a portion of their eligible family members' out-of-pocket medical expenses, such as deductibles, coinsurance and pharmacy expenses.

health savings account (HSA)

Allows members to save money into tax-advantaged accounts. Qualified contributions made to HSAs are tax-deductible, and funds withdrawn to pay for qualified medical expenses are tax-free.

O

Other Party Liability (OPL)

A cost containment program that recovers money for healthcare where primary responsibility does not exist because of another group health plan or contractual exclusions. Includes coordination of benefits, Workers' Compensation, subrogation and no-fault auto insurance.

P

point-of-service (POS) plan

A type of Health Benefit Plan that allows members to go outside the network for non-emergency care, but may result in a lower level of benefits being paid by the Health Benefit Plan.

S

State Children's Health Insurance Program (SCHIP)

Established by the Balanced Budget Act, this program is designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.

U

utilization review (UR)

An evaluation of the medical necessity, appropriateness and cost-effectiveness of healthcare services and treatment plans for a given patient.