A useful list to explain the toughest insurance terms

Covered services and treatment can be filed as a claim, but that doesn't mean the plan will pay 100%. In most cases, you'll pay a percentage of the cost, depending on your plan's deductible, copayments, and coinsurance.

Covered at 100%, which includes preventive care², means there is no extra cost to you. This distinction is important because this can often be confused.

If you ever have questions about what’s covered or not, just call the number on the back of your member ID card. Our Customer Service team can help.

When the ACA was signed into law in 2010, the government started requiring insurance companies to include what was considered to be essential health benefits on healthcare.gov.

Now, all health plans cover these services for their members:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Laboratory services
• Maternity and newborn care
• Mental health and substance use disorder services
• Pediatric services, including oral and vision care
• Pregnancy
• Prescription drugs
• Preventive and wellness services and chronic disease management
• Rehabilitative and habilitative services and devices

If you are an ACA member, be sure to take advantage of these essential health benefits. For example, see your doctor every year for a physical exam.

If you don’t have a primary care physician, use our Find Care tool³. It’s easy, it won’t cost you any extra money, and it will help identify any problems early on. If you cover any dependent children on your plan, their yearly eye and dental exams are covered, too.

If you had a health problem before your health insurance took effect, then you have a pre-existing condition. Common pre-existing conditions include asthma, cancer, high blood pressure, and diabetes. We won’t refuse to cover you or charge you a higher rate because of your pre-existing condition. 

These are things that aren’t covered by your health plan. You’ll have to pay out-of-pocket for these services. An excluded service may include cosmetic surgery or teeth whitening. There are other services that will be excluded on any health plan so you want to check ahead of your appointments. Use our Blue Connect℠ Mobile NC app to track your out-of-pocket expenses.

When your health plan starts, you’ll have to pay for the total cost of your care until you reach a certain amount. This amount is called a deductible, and it works just like your auto insurance deductible. Once you reach this amount, Blue Cross NC starts paying a percentage of the cost of your care.

Coinsurance is the percentage we pay for a covered service after the deductible has been met, and then you pay the difference in the amount owed. Some plans require you to pay a set dollar amount for each doctor’s visit or prescription medicine you buy. This is called a copayment. Your policy may require you to first meet your deductible.

Here's a real-life example:

Let’s say your deductible is $3,000, and your coinsurance is 80/20. Each time you visit your doctor or pick up prescription drugs, you’ll pay the negotiated rate owed to the doctor or pharmacy. When these treatment costs reach $3,000, Blue Cross NC will start paying 80% of these costs, and you’ll be responsible for 20%.

• After you hit your deductible, if your total bill is $1,000, Blue Cross NC pays $800 and you pay $200.
• Once you reach your out-of-pocket maximum – in this case, $6,000 – Blue Cross NC covers these costs at 100% until your health plan expires.

When you renew your health plan each year, the deductible and out-of-pocket maximum amounts reset.

We hope this makes your policy a little easier to understand. As you start using your health plan, call our customer service team with any questions.

We want to make sure your health plan works for you!