Understanding Insurance

Confused about health insurance? Many people are.

Take the guesswork out of health insurance in a few quick steps:

  1. Learn common health insurance terms.
  2. Find answers fast -- from how coverage works to paying bills.
  3. Take steps to get the right plan or get more from the one you have.

Still have questions? Contact us or find one of our retail stores for in-person help. Get details below.

Health Insurance Terms

There's a lot about insurance that can be hard to understand. We can help. You'll find short, clear definitions for some of the most used, but misunderstood terms under each tab here. To learn more:

Log in to Blue Connect

Deductible

The dollar amount you must pay for covered services in a benefit period before benefits are payable under the plan. The deductible does not include coinsurance, charges in excess of the allowed amount, amounts exceeding any maximum or expenses for non-covered services. Find your deductible amount on the Benefits page or read your Benefit Booklet for services that apply to your deductible.

In short:

A Deductible is the set dollar amount you pay toward covered medical services each benefit period (typically one year) before Blue Cross NC starts paying toward those services.

EOB (Explanation of Benefits)

EOBs show the price of a medical service, the amount Blue Cross NC will reimburse a provider based on negotiated rates, how much your plan paid, and your member savings. You’ll also see how much of your deductible you've paid, and any copayments, coinsurance or other amounts you may owe. And, the EOB will show you how much you may be able save by using in-network providers. Try the EOB Search Tool in Blue Connect to see details about your processed claims.

In short:

Members receive an EOB after a visit to a doctor, healthcare provider, pharmacy or facility. An EOB lists details of the medical service received including date, amounts paid by Blue Cross NC, and cost the member may owe.

Copayment

A copayment is the fixed dollar amount you pay at the time a covered service is provided. Copayment amounts can vary depending on:

  • Benefits or coverage included in your plan 
  • Service you receive
  • In-network vs. out-of-network doctor or hospital
  • Primary care provider (PCP) vs. specialist
  • Generic vs. brand-name prescription drugs

In short:

A Copayment is the set dollar amount you pay (for example, the $20 you pay when you check out at the doctor’s office) for medical services or prescription drugs at the time you receive them.

To learn more about Copayments log in to Blue Connect to read FAQs About Benefits and your Benefit Booklet.  

Coinsurance

Coinsurance is the sharing of costs by Blue Cross NC and you, the member, for covered services after you’ve met your benefit period deductible. Coinsurance is usually shown as a percentage.

For example, if your coinsurance is 20%, that means you'll pay 20% of covered medical expenses after you've met your deductible (and Blue Cross NC will pay 80%) until you reach your out-of-pocket limit for the benefit period.

Once you reach the out-of-pocket limit, Blue Cross NC covers 100% of all covered services for the remainder of the benefit period.

Find your coinsurance percentage on the Benefits page in Blue Connect, on your member ID card or in the Summary of Benefits in your benefit booklet.

In short:

Coinsurance is your share of the cost of a covered medical service after you’ve met your deductible for your benefit period.

Allowed Amount

The maximum amount that Blue Cross NC determines is reasonable for covered services provided to a member. The allowed amount includes any Blue Cross NC payment to the provider, plus any deductible, coinsurance, or copayment. For in-network providers, the allowed amount is the amount the provider has agreed to accept as payment in full.

In short:

The Allowed Amount is the maximum payment Blue Cross NC will pay for a covered health care service. If a provider charges more than the allowed amount, you may have to pay the difference.

In-Network / Out-of-Network Providers

An in-network provider is a hospital, doctor, other medical practitioner or provider of medical services and supplies that contracted with Blue Cross NC for your insurance plan or participates in the BlueCard program. Ancillary providers outside North Carolina are considered in-network only if they contract directly with the Blue Cross and Blue Shield plan in the state where services are provided, even if they participate in the BlueCard® program.

An out-of-network provider is a provider who does not contract with Blue Cross NC and does not participate in the BlueCard program.

In short:

In-Network Providers are health care providers and facilities that contract with Blue Cross NC or participate in the BlueCard program. You may pay less if you see an in-network provider.

Out-of-Pocket Limit

The out-of-pocket limit is the dollar amount you pay for covered services in a benefit period before Blue Cross NC pays 100% for covered services. The out-of-pocket limit can include your deductible, coinsurance and copayments, depending on your plan.

In short:

The maximum amount you pay for covered services in a benefit period (typically one year) before Blue Cross NC pays 100% of covered services. It can include your deductible, coinsurance and copayments, depending on your plan.

To learn more about your Out-of-Pocket Limit, log in to Blue Connect to read FAQs About Benefits and your Benefit Booklet.  


 

Get In the Know

Stay up to date and get the latest information about the Affordable Care Act, tips for getting the most from your plan and changes in health care.

Learn more on our blog, The Point of Blue.

Frequently Asked Questions

Now that you know the common terms and have more information about health insurance, find answers to more questions you may have.

Get information about:

  • ID Cards
  • Billing and payment
  • Claims
  • How to apply
  • Approvals and referrals
  • General coverage, and more.

Read FAQs

Take the Next Steps

Need health insurance? Find plans and get an instant quote.

Shop Plans

Need to talk to someone in person?

Visit a Retail Store

Or would you prefer to call, email, or even chat?

Contact Us