Glossary FAQ

What's the definition of subscriber liability?

Subscriber liability refers to any expenses a cardholder is responsible for, such as a deductible, a copayment, coinsurance, a sanction or a charge for a noncovered service.

What is a deductible?

The deductible is the amount a cardholder pays before his or her health plan begins to pay for covered services. Deductibles are required every calendar year. Example: If you have a $100 annual deductible, before your coverage begins to pay, you must pay the first $100 in charges for covered health care services.

What is a copayment?

A copayment is a fixed amount or a percentage of the approved amount a cardholder must pay for a covered service. Example: If you have a 20 percent copayment and received services costing $100. You are responsible for $20.

What is coinsurance?

Coinsurance is the term used by the Health Care Financing Administration to refer to the percentage of the Medicare approved amount that a beneficiary is responsible for paying.

What is a member sanction?

A member sanction is a percentage of the Blues' approved amount for a covered service that a member must pay when the member does not follow certain program guidelines. Example: If a cardholder fails to obtain a mandatory second surgical opinion, or uses providers outside a managed-care network without the proper referral, the member is required to pay a sanction. Some sanctions may require the cardholder pay the entire charge.

What about payment for noncovered services?

If a service is not covered under your health benefits plan, you must pay for it.

What is the difference between custodial care and skilled nursing care?

For insurance purposes, the distinction is important.

Custodial care can be provided safely and reasonably by people without professional skills or training to help patients with daily activities or personal needs, such as walking, getting in and out of bed, bathing, dressing and taking medicine. It also includes medical services, such as respiratory care, that a dedicated lay person can learn to perform. Custodial care is not covered by most insurance plans.

Skilled nursing care is furnished or supervised by a licensed nurse under the general direction of a physician to ensure the patient's safety and to achieve a medically desired result. Members who have skilled nursing care coverage are eligible for services when they require care that is at a lower level than provided in a hospital but is at a higher level than generally available on a outpatient basis, in the home or in a custodial or basic nursing home.

These are general guidelines; exact benefits are determined by your certificate and riders.

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