健康保险基本知识
Have questions about how health insurance works? You’re in the right place. Let’s go through the fundamentals so you have the knowledge you need to make your health plan work for you.
How health insurance works
Life can be unpredictable. Health insurance helps protect you and your loved ones from costly medical care by paying for certain health care services. Once you enroll in a health plan, the process works like this:
Every subscriber pays a monthly premium to maintain coverage. If you have insurance through your employer, that money comes directly out of your paycheck.
When you need health care, those premiums are used to cover a portion of your medical costs.
Your plan determines how much is covered by insurance and how much you pay out of pocket.
Important terms
We’ve gathered the top five health insurance terms our members ask about most often. Learn the lingo and feel better about using your plan.
Health plans have agreements with in-network providers and hospitals to offer discounted services and lower out of-pocket costs, like copays. When you visit an in-network provider or facility, your out-of-pocket expenses will be less than if you go out of network.
Real-life example:
Susan has a $25 copay for a sick visit with her PCP. If she visits a provider in the Blue Cross MA network, she’ll pay $25. If she visits an out-of-network provider, Susan will pay the full cost for her visit — likely much more than $25.
A deductible is the amount you pay for health care services before your health plan starts paying. Once you’ve met your deductible, your plan pays for covered services. Your deductible amount depends on the plan you select.
Real-life example:
Susan had a $2,000 deductible for the year. She had a sick visit with her PCP, for which she pays a $25 copay, a $200 diagnostic X-ray, and $4,000 shoulder surgery.
Susan paid her $25 copay for a sick visit. Copays don’t go toward a deductible. Her X-ray and surgery cost a total of $4,200. Because her deductible is $2,000, that’s the amount she paid out of pocket. Her health plan paid the remaining $2,200.
A copayment is a set amount you pay for certain out-of-pocket health care services, like office visits for an illness or injury. They’re typically a small fee, and they apply both before and after you’ve met your deductible. They don’t go toward paying down your deductible. For services that don’t have a copay, your deductible must be met before coverage kicks in.
Real-life example:
Peter’s copay for a sick visit with his PCP is $25. He’ll pay $25 for a sick visit whether he’s met his $2,000 deductible or not. Peter's copay won't go toward paying down his deductible.
Co-insurance kicks in after your deductible is met. It’s the percentage you pay for a covered health care service, while your health plan pays the rest. This is called cost-sharing. Once you’ve met your out-of-pocket maximum, your plan will pay 100% of covered health care services.
Real-life example:
Susan has already met her deductible for the year, and her co-insurance is 20%. She visits a specialist that costs $400. The co-insurance portion she must pay is $80 (20%), and her health plan pays the remaining $320 (80%).
Out-of-pocket costs refer to the expenses you pay for health care services that are not reimbursed by your plan. These include copays, co-insurance, and your deductible, as well as costs for services your plan doesn’t cover (like out-of-network care). Your out-of-pocket maximum is the most you’ll pay for covered services in a plan year before your health plan pays for 100% of covered services.
Real-life example:
Peter’s out-of-pocket maximum is $3,000 and his deductible is $2,000. His health plan will begin to cover 100% of his covered services after he’s met his $2,000 deductible and paid another $1,000.
What a health plan covers
What your health plan covers depends on the plan you choose for your unique needs. If you get insurance through your employer, you’ll choose from the plans they offer. Under your plan, some services may be covered in full, while others may have out-pocket-costs, like copays or co-insurance. Here’s a look at what a Blue Cross plan typically covers, including care everyone needs to stay healthy.
Preventive care helps you stay healthy through routine checkups, vaccines, screenings, and more. Most plans cover preventive care services at no cost. Learn more about the importance of preventive care.
Most plans cover visits to specialists, often requiring a copay. If you have an HMO plan, you need a referral to see a specialist. Find an in-network specialist.
Emergency and urgent care is covered with a copay under most plans. Find in in-network ER or urgent care center near you.
Your plan may come with pharmacy coverage. If it does, you’ll pay $0 or a copay for many prescription medications. Look up a Medication here to see if it’s covered by your plan.
Most plans cover services like diagnostic lab tests, MRIs, and X-rays. Find an in-work location for tests and imaging.
Part of preventive care, annual mental health wellness exams are covered by most plans. Learn more about the importance of mental health care.
Prenatal visits, labor and delivery care, well-baby visits, postpartum checkup, mental health support, and more are all covered by your plan. Learn more about family planning.
Most plans come with coverage for chronic condition management, including access to no-cost programs. Learn how we can support you.
Your plan comes with up to 30% off wellness offerings, including yoga, nutrition counseling, acupuncture, and massage therapy. Learn more about your options.
Check your plan for coverage details.
What a health plan doesn't cover
The health plan you choose also determines what’s not covered. Some plans offer more extensive coverage and are ideal for those who need more than preventive care. No matter the plan, here are just some of the things health insurance typically doesn’t cover:
- Elective procedures
- Cosmetic surgery
- Unapproved medical care
- Experimental treatments
- Off-label prescriptions
Why health insurance matters
For financial protection
When something unexpected happens, like an illness or accident, the medical bills pile up fast. Health insurance helps cover the cost.
For peace of mind
It helps to know there’s a limit to what you’ll pay for medical care. You can see a provider when you need to without worrying about the cost.
For your physical and emotional health
With health insurance, you’re covered for preventive care, like routine health checkups and cancer screenings. That makes it easier for you to get and stay healthy.
Questions? Call Team Blue Member Service at the number on your member ID card, or sign in to MyBlue to chat with a Member Service advocate.
