Health insurance 101

When you pay for certain services, those payments may not count toward you meeting your deductible. For details about exclusions, review your Blue KC certificate in your member account.

Each payment you make for covered healthcare services you’ve received from your providers such as a physical exam (not counting copays that you make at the time of your visits) counts toward your deductible. Once Blue KC processes the claims we receive from your providers showing the payments that you have made for covered healthcare services, we apply those payments toward your deductible.

A deductible is the amount that you are responsible for paying annually for healthcare services. You pay coinsurance after you’ve met your deductible. Exceptions are outlined in your Blue KC certificate, found in your member account, which lists the exclusions related to your health insurance plan.

A copayment, or copay, is the dollar amount that you pay to a provider at the time you receive a service. For example, you might pay a $30 copay each time you visit your allergy doctor. The copay amount is defined in your Blue KC certificate, found in your member account, which outlines your responsibilities for health insurance plan payments.

Providers who have entered into a contract with Blue KC have agreed to accept a specific payment amount for each of their services. This is often a discounted amount versus what these providers might normally charge. The provider write-off is the difference between what they normally charge and the discounted amount specified in our agreement with that provider. We refer to this as the “provider write-off.” Ultimately three things determine what Blue KC pays a provider:

• The agreed-upon fee
• The amount of your copayment and/or coinsurance
• The amount of your deductible that has been satisfied

Allowable charges are the maximum amount payable to you under your health insurance plan for a particular service. Contracted providers have agreed to accept this amount as payment in full. For example, if the provider charges $100 for a service and Blue KC pays $80 as the allowable charge, the provider cannot ask the member to pay the remaining $20. Keep in mind, however, that some health insurance plans have coinsurance. In those cases, members are required to pay a percentage of the allowable charge. For specific details about your plan, review your Blue KC certificate found in your member account, which outlines your payment responsibility.

Billed charges are the amount charged or billed by your healthcare provider for the services/supplies you received. Not all provider charges will be paid by your health insurance plan.

Coverage is health insurance that a member receives for covered services.

In-network: A hospital, pharmacy, physician or other medical service provider that has a contract to participate in one or more plans with Blue KC. A provider who is considered in-network for one plan may be considered out-of-network for another plan.

Out-of-network: A hospital, pharmacy, physician or other medical service provider that does not have a network contract with Blue KC to provide healthcare services to members. Both non-participating providers and non-preferred providers are also referred to as out-of-network providers. PPO members who visit an out-of-network provider will receive limited benefits. EPO and HMO members will not receive any benefits except in the case of an emergency.

An EPO (Exclusive Provider Organization) is similar to an HMO as it is a healthcare plan type that covers eligible services from providers and facilities inside a network. Generally, an EPO does not pay for any services from out-of-network providers and facilities except for emergency services, which is similar to an HMO. Unlike an HMO, EPO participants are not usually required to have a primary care physician or referrals.

A PPO (Preferred Provider Organization) is a healthcare plan that allows people to see doctors or get services that are not part of a network. Those out-of-network services are at a higher rate, though. Plans are structured so that members will pay less money out-of-pocket when they use in-network providers.

Most benefit plans have an out-of-pocket maximum. If the total dollar amount that you have paid in deductibles, coinsurance, and in some cases copayments, reach this maximum amount in a calendar year, then the insurer will pay 100 percent of the allowed charges for the remainder of the year.

Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

Coinsurance is the percentage of an allowable charge that a member pays, not including any copayments or deductibles. For example, if the member’s plan has an 80/20 coinsurance rate, the insurer will pay 80 percent of the allowable charge for eligible medical expenses and the member will pay the remaining 20 percent.

A copay is the dollar amount that a member usually pays each time that a covered service is performed. If the member’s plan has a copayment amount, it is typically listed on the member ID card.

A premium is the amount a member or group pays on a periodic basis for coverage as defined in the member’s health insurance certificate or contract.

When you pay for certain services, those payments may not count toward you meeting your deductible. For details about exclusions, review your Blue KC certificate in your member account.

Each payment you make for covered healthcare services you’ve received from your providers such as a physical exam (not counting copays that you make at the time of your visits) counts toward your deductible. Once Blue KC processes the claims we receive from your providers showing the payments that you have made for covered healthcare services, we apply those payments toward your deductible.

A deductible is the amount that you are responsible for paying annually for healthcare services. You pay coinsurance after you’ve met your deductible. Exceptions are outlined in your Blue KC certificate, found in your member account, which lists the exclusions related to your health insurance plan.

A copayment, or copay, is the dollar amount that you pay to a provider at the time you receive a service. For example, you might pay a $30 copay each time you visit your allergy doctor. The copay amount is defined in your Blue KC certificate, found in your member account, which outlines your responsibilities for health insurance plan payments.

Providers who have entered into a contract with Blue KC have agreed to accept a specific payment amount for each of their services. This is often a discounted amount versus what these providers might normally charge. The provider write-off is the difference between what they normally charge and the discounted amount specified in our agreement with that provider. We refer to this as the “provider write-off.” Ultimately three things determine what Blue KC pays a provider:

• The agreed-upon fee
• The amount of your copayment and/or coinsurance
• The amount of your deductible that has been satisfied

Allowable charges are the maximum amount payable to you under your health insurance plan for a particular service. Contracted providers have agreed to accept this amount as payment in full. For example, if the provider charges $100 for a service and Blue KC pays $80 as the allowable charge, the provider cannot ask the member to pay the remaining $20. Keep in mind, however, that some health insurance plans have coinsurance. In those cases, members are required to pay a percentage of the allowable charge. For specific details about your plan, review your Blue KC certificate found in your member account, which outlines your payment responsibility.

Billed charges are the amount charged or billed by your healthcare provider for the services/supplies you received. Not all provider charges will be paid by your health insurance plan.

Coverage is health insurance that a member receives for covered services.

In-network: A hospital, pharmacy, physician or other medical service provider that has a contract to participate in one or more plans with Blue KC. A provider who is considered in-network for one plan may be considered out-of-network for another plan.

Out-of-network: A hospital, pharmacy, physician or other medical service provider that does not have a network contract with Blue KC to provide healthcare services to members. Both non-participating providers and non-preferred providers are also referred to as out-of-network providers. PPO members who visit an out-of-network provider will receive limited benefits. EPO and HMO members will not receive any benefits except in the case of an emergency.

An EPO (Exclusive Provider Organization) is similar to an HMO as it is a healthcare plan type that covers eligible services from providers and facilities inside a network. Generally, an EPO does not pay for any services from out-of-network providers and facilities except for emergency services, which is similar to an HMO. Unlike an HMO, EPO participants are not usually required to have a primary care physician or referrals.

A PPO (Preferred Provider Organization) is a healthcare plan that allows people to see doctors or get services that are not part of a network. Those out-of-network services are at a higher rate, though. Plans are structured so that members will pay less money out-of-pocket when they use in-network providers.

Most benefit plans have an out-of-pocket maximum. If the total dollar amount that you have paid in deductibles, coinsurance, and in some cases copayments, reach this maximum amount in a calendar year, then the insurer will pay 100 percent of the allowed charges for the remainder of the year.

Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

Coinsurance is the percentage of an allowable charge that a member pays, not including any copayments or deductibles. For example, if the member’s plan has an 80/20 coinsurance rate, the insurer will pay 80 percent of the allowable charge for eligible medical expenses and the member will pay the remaining 20 percent.

A copay is the dollar amount that a member usually pays each time that a covered service is performed. If the member’s plan has a copayment amount, it is typically listed on the member ID card.

A premium is the amount a member or group pays on a periodic basis for coverage as defined in the member’s health insurance certificate or contract.