Common terms

and definitions

Knowing the definitions of some common

terms associated with health insurance-charlotte nc may

help you make better decisions about which

plan is right for you.

Premium

A periodic payment made to BCBSNC to keep your health

insurance policy active charlotte NC. Premiums are separate from other costs,

like copayments, deductibles and coinsurance.

Copayment

A fixed dollar amount that you pay to a provider at the time certain

Blue Advantage-covered services are provided. For example, the

price you pay for an office visit or a prescription medication.

Deductible

The amount you pay your insurance provider each benefit period

for certain covered services before your health insurance charlotte nc begins

paying toward those future covered services. An example would

be medical care or prescription medications.

Family deductible (For Blue Advantage)

A family deductible for Blue Advantage is met once three members

on a family policy each meet their individual deductibles.

Family aggregate deductible

(For Blue Options HSA)

A family deductible for Blue Options HSA is a deductible that has

to be met before any benefits are payable for any given member

in a family. Under a family aggregate deductible, services for all

family members who are covered under the plan get applied to

the same deductible.

Coinsurance (For Blue Advantage)

The percentage of covered medical expenses that you pay

after you’ve paid your deductible. Coinsurance is usually listed

as a percentage. So if BCBSNC lists coinsurance at 20% of

covered medical expenses after you’ve met your deductible,

then BCBSNC pays 80% and you pay 20% until you reach your

coinsurance maximum.

Coinsurance maximum (For Blue Advantage)

The total amount of coinsurance that you’re required to pay

for covered medical services in a year. Once you reach the

coinsurance maximum, BCBSNC covers 100% of all covered

services for the remainder of the benefit period. You may

continue to pay copayments for covered services.

Preferred provider organization (PPO)

A health plan that contracts with various physicians and

hospitals. PPO members are offered a financial incentive to use

providers on a preferred list, but some use out-of-network

providers at a higher cost.

Total out-of-pocket maximum

(For Blue Options HSA)

The total amount of money you will pay out of pocket during a

benefit period. Once you reach the total out-of-pocket

maximum, BCBSNC covers 100% of all covered services for the

remainder of the benefit period. Total out-of-pocket maximum

includes deductible and coinsurance that you pay, and is

determined whether you have individual or family coverage.

Health savings account (HSA)

An HSA is a tax-free way to help pay for current or future out-ofpocket

health care expenses.7 To be eligible to open an HSA and

begin saving money for medical expenses tax-free, you must be

covered by a high-deductible health plan. BCBSNC will set up

an HSA for you when you purchase a Blue Options HSA health

plan. Then you will be able to make contributions to this account.

Dollars that are not used in a given year roll over into the next

year and are completely portable should you change jobs or

switch health care coverage.

High-deductible health plan (HDHP)

A high-deductible health plan is a health plan product that, when

combined with an HSA, provides insurance coverage and a

tax-advantaged way to help save for future medical expenses.

An HDHP typically has a lower premium with a higher annual

deductible than a traditional health plan and must meet other

specific federal guidelines. With the exception of preventive care,

members covered under high-deductible health plans do not

have benefits for any coverage prior to meeting the deductible.

That means the member pays for covered services such as office

visits, emergency room visits and prescription drugs out of pocket

until the deductible is reached.

Common questions
about health insurance
If you’re looking for health insurance, chances are you
have a lot of questions. Take a look at some of the
most common health insurance questions we receive

If I apply online for an insurance plan,
am I obligated to buy?
No. You’re under no obligation to buy a health insurance plan.
Once you’ve received a final decision after applying, you’ll be
given the option to review the original plan you selected, as well
as other plan options available to you.
What’s the difference between in-network

In-network providers are contracted with BCBSNC to provide
services to members at discounted rates. Out-of-network
providers aren’t contracted, so their services usually cost more
for members. Plus, BCBSNC generally pays a lower percentage
for these services, which also may increase member out-ofnetwork
provider costs

What’s a pre-existing condition and how does
it affect my plan if I have one?
A pre-existing condition is a condition, disease, illness or injury
for which medical advice, diagnosis, care or treatment was
received or recommended within the 12-month period prior to
the effective date of your health insurance plan.18 If you have a
pre-existing condition, any medications, doctor visits or surgeries
related to this condition won’t be covered until 12 months after
the policy’s effective date. If you had other coverage before
enrolling in a plan, without a lapse of 63 days or more, your
waiting period for pre-existing conditions will be reduced by the
number of days that you had prior coverage

How much do I have to pay if I get really sick?
With all of our plans, there are maximum limits you’ll pay for your
covered services each year that help protect you from endless
medical bills. Blue Advantage plans have coinsurance maximums
and Blue Options HSA plans have total out-of-pocket maximums.
See page 11 for more detailed definitions

Do I have to meet the deductible before I pay
copayments for my doctor visits?
No. Deductibles and copayments work separately. For each
covered service provided, you may be charged a copayment
or a deductible, not both. Generally, copayments are a fixeddollar
amount paid at the time of service – like for an office
visit or a prescription – whereas deductibles go towards paying
for covered services before your health insurance begins
paying toward those expenses. Some prescription plans have
a separate deductible that’s required before prescription drug
copayments begin

Do copayments count toward the deductible?
No. Copayments don’t count toward deductibles. They’re a flat
rate fee separate from your deductible costs

What is an HSA?
An HSA is a health savings account that allows you to save
money to pay for future medical expenses on an income-tax-free
basis. The HSA is connected to a high-deductible health plan
that doesn’t have copayments. You pay out of pocket until your
deductible is met for all services, excluding a predefined list of
preventive services that are covered at 100% (no cost to you)
each year.3

What does “coinsurance after the benefit
period deductible” mean with a health
savings account (HSA)?
Since there are no copayments with a Blue Options HSA, you
pay the total cost of your care until your deductible is met –
even for doctor’s visits, unless it is for preventive care.3 After
that, you pay coinsurance for covered medical expenses until
you reach your total out-of-pocket maximum. Once the total
out-of-pocket maximum is met, BCBSNC pays 100% of covered
medical expenses

What if I only need insurance for my child
and not for myself – how do I purchase it?
You can purchase a Blue Advantage or Blue Options HSA policy to
cover your child or adopted/foster child without being covered by
the policy yourself. Your child will receive full Blue Advantage or
Blue Options HSA benefits, including immunization, well-child and
well-baby care coverage. When you apply, be sure to enter
your child’s information (name, gender and birth date) as the
primary applicant. If you plan to cover multiple children, each
child must have his or her own policy, so you’ll need to apply
for each policy separately. Multiple children may be covered on
the same Blue Advantage or Blue Options HSA policy, as long
as the parent is covered by the same policy.
You can cover children up to age 26 on your policy, as long as
they are your legal dependents. However, children under age
18 are not eligible to have their own health savings account.
Children under age 18 are subject to certain tax guidelines.
Consult a tax professional for more information.

What are my options for a maternity rider?
For an extra charge, a maternity rider is available when you
first purchase your Blue Advantage or Blue Options HSA policy,
renew your policy (if the policy has been in effect for at least six
months) or if you have a family status change, such as marriage.11
A maternity rider is available only for adult females age 18 and
over (subscribers or spouses) who are not pregnant at the time
a maternity rider is selected and are not on a child-only policy.
Services are subject to deductible and coinsurance

How do I get dental coverage with my plan?
Dental coverage is available through Dental Blue for
IndividualsSM, a separate plan that provides dental-only coverage
at an additional cost to your health plan premium,12 and it’s
available with or without the purchase of a health plan. Dental
Blue for Individuals covers two (2) preventive care visits at 100%
each year. Basic services and major services are covered (in part)
after you meet your dental deductible

If I get a Blue Options HSA health plan, do I have
to worry about finding and setting up the HSA?
No. BCBSNC sets up an HSA automatically when you purchase
a Blue Options HSA health plan. You must be 18 or older to be
eligible for an HSA. Then you can make contributions into an
FDIC-insured checking account, administered by Mellon Trust of
New England, N.A.1 Once you’ve registered your signature, you
can use your HSA checkbook or debit card to pay for provider
services. Simply show the provider your BCBSNC ID card and
pay, either at the time of service or later when you receive a bill.

Limitations & Exclusions
Like most health care plans, Blue Advantage and Blue Options
HSA have some limitations and exclusions. You must qualify
medically. If your application is approved, you will receive a
Member Guide. It will contain detailed information about plan
benefits, exclusions and limitations.
This is a partial list of benefits that are not payable to either Blue Advantage or
Blue Options HSA:

Our traditional PPO plan

Blue Advantage is a PPO plan – a preferred provider organization
plan – which means you pay convenient copayments or coinsurance
for things like primary care visits, specialist office visits and
prescription drugs.9