Tips

You are responsible for your health care, so it helps to be informed. Below are commonly used health insurance terms; familiarize yourself with the definitions as they will help you better understand your coverage.

Allowed Amount - Blue Cross and Blue Shield calculates payment of your benefits based on the allowed charge (sometimes referred to as the allowed amount). This is the maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance, or negotiated rate. The allowed charge that Blue Cross Blue Shield uses depends on the type of health care provider that furnishes the covered service to you.

Balance Billing - There may be times when a health care provider bills you for the difference between what they charge for a service and what is allowed for payment (see above for a description of the allowed amount). This is referred to as balance billing. It often happens when you seek care from an out-of-network provider. In-network providers cannot balance bill you for covered services.

Coinsurance - A form of cost-sharing requiring the member (i.e., the health plan participant) to pay a percentage of the cost for medical care, typically after a deductible has been reached. Coinsurance rates may differ between services received from an in-network physician/facility and those received from an out-of-network physician/facility.

Copayment - A cost-sharing arrangement in which the member pays the provider a specified flat dollar amount for a specific service and the benefit plan pays the balance.

Deductible - The fixed dollar amount a member must pay before the plan begins to pay benefits during the plan year. Plans may have both individual and family deductibles. Deductibles may differ between services received from an in-network physician/facility and those received from an out-of-network physician/facility.

Flexible Spending Account (FSA) - These tax-favored accounts allow an individual to set aside pre-tax dollars from their salary to reimburse themselves for certain qualified out-of-pocket expenses. Most aspects of the account are regulated by the Internal Revenue Service (IRS).

In-Network Providers - Physicians and facilities with whom the health plan has a contract or an agreement specifying discounted payment levels and other requirements, also called participating providers.

Out-of-Network Providers - Physicians and facilities who do not have a contract or an agreement with the health plan. When members obtain services from an out-of-network provider, they typically pay a higher percentage of the total costs. Some plan types—such as an HMO—do not provide any benefits for out-of-network providers. Also called non-participating providers.

Out-of-Pocket Maximum - The total amount a member is required to pay for services during the plan year. The out-of-pocket maximum generally includes the deductible, member-paid coinsurance, and copayments. It does not include monthly insurance premiums, which are deducted from pay. After a  member reaches the out-of-pocket maximum, the plan pays 100 percent of covered charges for the rest of that plan year. Plans may have both individual and family out-of-pocket maximums. The out-of-pocket maximum may differ between services received from an in-network physician/facility and those received from an out-of-network physician/facility

Preventive care includes services such as routine check-ups, screening tests, and immunizations for when you are symptom-free and have no reason to believe that you might be sick.

Diagnostic care includes tests/procedures ordered by a physician and office visits needed to help diagnose or monitor your condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services, and other tests.

Preventive and diagnostic care may occur during the same visit. For example, during a routine check-up your doctor discusses a chronic illness you may have. The tests your doctor orders may be preventive (such as a screening mammogram) and other tests may be diagnostic (such as a cholesterol check for someone with high cholesterol).

Why you need to understand the difference:
Understanding the difference between preventive and diagnostic care will help you anticipate when cost sharing applies to certain services. In most cases, you do not pay for preventive care; however, cost sharing applies to diagnostic care. When both preventive and diagnostic care occur during the same visit, you pay something for the diagnostic services (i.e., co-payment, deductible, and/or co-insurance).

With Express Scripts online service and mobile app, you can view or print your member ID card, manage your medications, find a Pharmacy, and more.

Online access offers you convenience and access to savings. Learn more about Express Scripts' online services and app.

You may have to pay for medical services at the time you receive care and file for reimbursement later.

If you receive medical care, you will need the following items to file a claim:

• Receipt of payment(s)
• An itemized bill listing the service(s) you received and the cost associated with each line of service
• Inpatient care will require a copy of your medical record (from the hospital that you were admitted to)

Complete an International claim form.

When you are covered under more than one health insurance plan, Blue Cross Blue Shield will decide which plan is the primary payor and the secondary payor. This is referred to as Coordination of Benefits (COB). However, if the non-HUGHP health insurance plan you are covered under does not include COB rules that are consistent with Blue Cross Blue Shield COB rules, that plan will determine benefits before this health plan. For more information on COB, view your HUGHP Plan Benefit Description or contact Blue Cross Blue Shield at (800) 257-8141.   

Benefits are not provided for exams and tests that are required by a third party. Some examples of third-party requests are:

• Recreational activities
• Employment, insurance, school, court-ordered exams and services, except when they are medically necessary services

For more information, view your HUGHP Plan Benefit Description.