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A useful list to explain the toughest insurance terms

You just received your Blue Cross and Blue Shield of North Carolina (Blue Cross NC) health insurance papers in the mail. No matter how long you stare at them, there is a chance that you still don’t understand what anything written on the documents actually means.

Sound familiar? Don’t worry! Health insurance can be complicated, but it doesn’t have to be. And we’re here to help! To make sure you understand your plan, we’re outlining the most common terms that often confuse our members.

The open enrollment period for ACA coverage runs from November 1 to January 15 in North Carolina. Outside of that window, you'll need a qualifying life event in order to enroll or make a change to your coverage.

Premiums, benefits and services

When you signed up for your health plan, you agreed to pay a monthly fee to Blue Cross NC. This monthly fee is called a premium. Your premium stays the same each month until your plan expires. You’ll want to pay your premium on time each month so your plan stays active.

Benefits are services you receive from your health insurance company. You can find a list of your benefits in the coverage documents you received in the mail. You’ll see there are benefits that are “covered,” and some that are “excluded.”

The difference between “covered” and “covered at 100%”

“Covered” means eligible to be filed as a claim on your plan and that it doesn’t mean the plan will pay 100%. Covered at 100% (such as preventive care) has a different meaning. 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.

Essential health benefits

When the Affordable Care Act (ACA) was signed into law in 2010, the government started requiring insurance companies to include what was considered to be essential health benefits on

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

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

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 tool. It’s easy, it won’t cost you any extra money, and it will help identify any problems early on. If you cover dependent children on your plan, their yearly eye and dental exams are covered, too.

Pre-existing conditions

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. Preventive care is an important part of your overall health plan. Don’t let disease sneak up on you. Preventive care might just save your life.

Excluded services

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, teeth whitening or massage therapy. 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 app to track your out-of-pocket expenses.

Deductibles, coinsurance and copayments

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.

Once you hit your deductible amount, Blue Cross NC starts paying for a portion of the covered services you receive. Coinsurance is the percentage we pay, 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 medicine, you’ll pay the full amount owed to the doctor or pharmacy. When your doctor visits and / or medicine total $3,000, Blue Cross NC will start paying 80% of these costs, and you’ll be responsible for 20%.

  • So 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!

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