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Insurance 101: Understanding Your Medical Plan


Choosing a medical plan is the first step in making sure you have access to the care you need, when you need it. An essential second step is making sure you know what terms like deductible, copay and total network out-of-pocket maximum mean so you can make fully informed decisions about your health care.

What is a primary care provider?

A primary care provider (PCP) is the medical professional you choose to treat and coordinate your health care needs. He or she is the first person you call (unless it’s an emergency) to take care of you when you are sick, or guide you if you need more care. Your PCP can also help you stay up to date with yearly exams, immunizations and health screenings. HealthSelect of Texas® participants must choose a PCP to get the highest level of benefits.

What is an in-network provider?

Your HealthSelect of Texas® plan uses doctors, hospitals and other health care professionals that are part of what’s called a “provider network.” If you visit a provider outside of your plan’s network, you will likely have to pay more for your care. In some cases, you may have to pay the full cost. The best way to find in-network providers is by logging into Blue Access for MembersSM, your online participant portal, for a personalized search based on your health plan. (Note: You can search for an in-network provider without logging into Blue Access for Members if you prefer.) If you are enrolled in HealthSelect of Texas and you do not choose a PCP by the end of your grace period (see definition of “grace period” below), you will get out-of-network benefits for any services you get, even if your provider is in-network.

What is a deductible?

A deductible is how much you have to pay out-of-pocket for health care before your health plan starts to pay for any covered services, except preventive care, in a year. All HealthSelect plans have a $50 per person, per year prescription drug deductible. HealthSelect of Texas, HealthSelect Out-of-State and Consumer Directed HealthSelectSM plans have a deductible for out-of-network medical care. Consumer Directed HealthSelect and HealthSelect Secondary also have deductibles for in-network medical care. In-network preventive services are covered at 100% before you meet your annual deductible. Learn more about covered preventive care services.

What are copays?

When you see your PCP or other health care professionals, you often have a copay, which is a set dollar amount you must pay for certain covered health services, usually at the time you get the service. For example, HealthSelect of Texas has a $25 copay per visit to your in-network PCP for non-preventive care. So if you see your PCP for a sore throat, you will pay $25 at your visit.

What is coinsurance?

Coinsurance is the percentage of your plan’s allowable amount you must pay for some services, after you've met your deductible, if you have one. (See definition of “allowable amount” below.) For example, if the plan’s allowable amount for a lab test is $100, and your coinsurance is 20%, you are responsible for paying $20. Your health insurance plan pays the other $80. If your plan has a deductible, and you haven't met that deductible, you will pay the full $100.

What is a total network out-of-pocket maximum?

There is a limit for how much you will have to spend on your in-network health care costs in a calendar year. This is called the total network out-of-pocket maximum. This maximum helps protect you from catastrophic health care costs. Your deductible, copays and coinsurance for in-network covered health services and prescription drugs apply to the total network out-of-pocket maximum. After you meet this limit, the plan will pay 100% of the allowable amount for covered services provided by an in-network provider or facility. All HealthSelect plans have the same total out-of-pocket maximum for covered in-network health and prescription drug costs. The total out-of-pocket maximum resets on January 1 for HealthSelect of Texas, HealthSelect Out-of-State, HealthSelect Secondary and Consumer Directed HealthSelect.

What is a referral?

A referral is a written order submitted to Blue Cross and Blue Shield of Texas (BCBSTX) from your PCP for you to see a specialist. If you are enrolled in HealthSelect of Texas, you need to obtain a referral for most services before you can get medical care from anyone except your PCP. If your PCP decides that you need to see a specialist, he or she will need to submit a referral to BCBSTX before your visit. If you see a specialist without a valid referral on file with BCBSTX, you will pay more because your visit will be considered out-of-network. In most cases, a referral is good for 12 months. (Referrals are not required for the HealthSelect Out-of-State, Consumer Directed HealthSelect or HealthSelect Secondary plans.)

What is a prior authorization?

A prior authorization is a review process used to determine whether certain services are covered. A prior authorization confirms that a provider’s plan of treatment is the most appropriate level of care for your medical situation.

You need prior authorization for certain covered health services before you receive them. Your PCP and other in-network providers are responsible for getting prior authorization before they provide these services to you. If you choose to get certain covered health services from out-of-network providers, you are responsible for getting prior authorization from BCBSTX before you get these services.

What is an allowable amount?

The allowable amount is the maximum amount the plan will pay for a health care service. Allowable amounts are contracted between BCBSTX and providers who agree to participate in the HealthSelect network.

Remember: it pays to stay in network! If you get services from an in-network provider, you are not responsible for the difference in cost between the allowable amount and the amount the provider bills. For example, you see an in-network specialist who bills $150 for a service. The allowable amount is $100. You will pay $40 and HealthSelect of Texas will pay $60. You are not responsible for the additional $50 that is over the allowable amount. If you are enrolled in Consumer Directed HealthSelect, you will have to pay the full allowable amount for a service until your deductible is met before benefits are paid by the plan. And, as shown in the example above, you don’t have to pay the difference between the billed and allowable amount for in-network providers.
For certain out-of-network services, you may be responsible for paying the out-of-network provider any difference between the amount the provider bills you and the amount paid by the plan. This is also referred to as balance billing.

What is a grace period?

If you enroll in HealthSelect of Texas and do not select a PCP at the time you enroll, you have a 60-day grace period from the effective date of your coverage to select a PCP. During the grace period, before you select a PCP, in-network benefits will apply when you visit any in-network provider. (Remember: a valid referral from an in-network PCP is required to see a specialist.) Once you select a PCP, the grace period ends, and all services must be coordinated through your PCP. If, after you select a PCP, you get services from a provider without a valid referral from your PCP on file with BCBSTX, out-of-network benefits apply. If you do not choose a PCP by the end of your grace period, you will get out-of-network benefits for services you get, even if your provider is in-network.

Need more details?

Watch this video that discusses common terms related to health care cost sharing in your health plan.

To find deductibles, copays, coinsurance and total network out-of-pocket maximum amounts for the HealthSelect plans, view the Health Plans Comparison Chart.

If you have questions about how specific services are covered on your HealthSelect plan, visit the Publications and Forms page. You’ll find a Master Benefit Plan Document for your HealthSelect plan. You can also call a BCBSTX Personal Health Assistant. BCBSTX Personal Health Assistants are trained to help you and your covered family members make the best use of your health insurance benefits, which may save you money. Call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday – Friday 7 a.m. – 7 p.m. and Saturday 7 a.m. – 3 p.m. CT.

Want to test your medical insurance terms knowledge? Test yourself with this crossword puzzle. For best results, print the puzzle. Do your best and then come back to check your answers!


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