Even More Useful Georgia Health Insurance Definitions

Network Hospital
A Hospital located in Georgia which is a party to a written agreement with, and in a form approved by, BCBSHP to provide services to its Participants; or a Hospital outside of Georgia which is a party to an agreement with another Blue Cross and Blue Shield HMO BLUE USA Plan.

Network Provider
A Physician, Skilled Nursing Facility, Hospice, Home Health Care Agency, other medical practitioner or provider of medical services and supplies in the Service Area that has a Network Provider contract with the Claims Administrator to provide Covered Services to Participants. Also referred to as In-Network Provider.

New Hire
A person who is not employed by the Group on the original Effective Date of the Health Plan Document.

Non-Covered Services
Services that are not benefits specifically provided under the Plan, are excluded by the Plan, are provided by an Ineligible Provider, or are otherwise not eligible to be Covered Services, whether or not they are Medically Necessary.

Non-Participating Provider
A Hospital, Physician, Freestanding Ambulatory Facility (Surgi-Center), Skilled Nursing Facility, Hospice, Home Health Care Agency, other medical practitioner or provider of medical services or supplies, that does not have a Participating Agreement with the Claims Administrator to provide services to its Participants at the time services are rendered.

Out-of-Area Urgent Care
Covered Services required in order to prevent serious deterioration of a Participant's health that results from an unforeseen illness or Injury if the Participant is temporarily absent from the BCBSHP Service Area and receipt of the health care service cannot be delayed until the Participant's return to the Service Area.

Out-of-Network Provider
A Hospital, Physician, Skilled Nursing Facility, Hospice, Home Health Care Agency, other medical practitioner or provider of medical services and supplies, that does not have a Network Provider contract with the Claims Administrator. This provider may also be referred to as a Non-Network provider.

Out-of-Pocket Limit
The maximum amount of a Participant's Coinsurance payments during a given Calendar Year. Such amount does not include Copayment amounts or fees in excess of Providers' reasonable fees. When the Out-of-Pocket Limit is reached, the level of benefits is increased to 100% of Eligible Charges for Covered Services, exclusive of Copayments and other scheduled fees.

Participant
The Subscriber and each Dependent, as defined in this SPD booklet, while such person is covered by this Plan.

Participating Hospital
A Hospital located in Georgia which is a party to a written agreement with, and in a form approved by, Blue Cross Blue Shield of Georgia, Inc.; or a Hospital outside of Georgia which is a party to an agreement with another Blue Cross and Blue Shield Plan; or a Hospital outside Georgia located in an area not served by any Blue Cross and Blue Shield Plan.

Participating Provider
A Hospital, Physician, Freestanding Ambulatory Facility (Surgical Center), Skilled Nursing Facility, Hospice, Home Health Care Agency, other medical practitioner or provider of medical services or supplies that has signed a Participating Agreement with BCBSGA to accept its determination of Usual, Customary and Reasonable Fees (UCR) or other payment provisions for Covered Services rendered to a Participant who is his or her patient.

Periodic Health Assessment
A medical examination that provides for age-specific preventive services that improve the health and well- being of a patient being examined. This examination is provided through the network by Primary Care Physicians. The frequency and content of the health assessment are determined by established guidelines and the Participant's personal history.

Physician
Any licensed Doctor of Medicine (M.D.) legally entitled to practice medicine and perform surgery, any licensed Doctor or Osteopathy (D.O) approved by the Composite State Board of Medical Examiners, any licensed Doctor of Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and any licensed Doctor of Dental Surgery (D.D.S.) legally entitled to perform oral surgery; Optometrists and Clinical Psychologists (Ph.D) are also providers when acting within the scope of their licenses, and when rendering services covered under this Plan.

Plan
The arrangement chosen by the Plan Sponsor to fund and provide for delivery of the Plan Sponsor's health benefits.

Plan Administrator
The person named by the Plan Sponsor to manage the Plan and answer questions about Plan details.

Plan Sponsor
The legal entity that has adopted the Plan and has authority regarding its operations, amendments and terminations.

Premium
The amount that the Group or Participant is required to pay the Claims Administrator to continue coverage.

Prescription Drug
A drug which cannot be purchased except with a prescription from a Physician and which must be dispensed by a pharmacist.

Primary Care Physician (PCP)
A licensed Physician who is a Participating Provider trained in general family practice, pediatrics or internal medicine, and has entered into an agreement to coordinate the care of Participants. Your Primary Care Physician provides initial care and basic medical services, assists you in obtaining pre-certification of Medically Necessary Referrals for Specialist and Hospital care, and provides you with continuity of care.

Professional Ambulance Service
A state-licensed emergency vehicle which carries via the public streets injured or sick persons to a Hospital. Services which offer non-emergency, convalescent or invalid care do not meet this definition.

QMCSO - Qualified Medical Child Support Order
A QMCSO creates or recognizes a right of a child who is recognized under the order as having the right to be enrolled under the health benefit plan to receive benefits for which the Employee is entitled under the Plan; and includes the name and last known address of the Employee and each such child, a reasonable description of the type of coverage to be provided by the Plan, the period for which coverage must be provided and each plan to which the order applies.

Referral
Specific instructions from a Participant's Primary Care Physician, in conformance with the policies and procedures, that direct a Participant to a In-Network Provider for Medically Necessary care.

Reimbursement Rate
The percentage of Eligible Charges calculated each year by the Claims Administrator and BCBSGA for any In-Network or Participating Hospital. The payment rate will be applied to all Hospital Inpatient and outpatient claims during the payment period, including Out-of-Network and Non-Participating Hospitals.

Respite Care
Care furnished during a period of time when the Participant's family or usual caretaker cannot, or will not attend to the Participant's needs.

Retiree
A person who has met all of the conditions for continuation of Plan coverage as an eligible Retiree as detailed in the Eligibility section of this Summary Plan Description.