Deductible
A deductible is the amount of money you or your dependents must pay toward a health claim before your insurance plan makes any payments for healthcare services rendered. This is an annual amount calculated during the plan year, January through December.
Copays
Copays are a set dollar amount that you pay toward the cost of covered medical services. Typically, you might see a copay for prescription drugs.
Coinsurance
The amount or percentage that you pay for certain covered healthcare services under your health plan. This is typically the amount paid after the deductible is met, and can vary based on the plan design.
Out-of-Pocket Maximum (OOPM)
An out-of-pocket maximum is the maximum amount that an insured will have to pay out of their own pocket for covered expenses under a plan. Deductibles, copays, and coinsurance all accumulate towards the OOPM. This is an annual amount calculated during the plan year, January through December. In-network and out-of-network OOPM accumulate jointly.
Explanation of Benefits (EOB)
When you incur an expense, a claim is filed on your behalf with Blue Cross Blue Shield of ND. Once Blue Cross Blue Shield of ND processes the claim, you will receive an EOB. The EOB tells you the total amount of the claim, what the provider must “write off” based on their provider contract with Blue Cross Blue Shield of ND, what Blue Cross Blue Shield of ND paid, and what you owe on the claim. The EOB also shows what’s accumulated toward your annual deductible and OOPM, if applicable.
Preventive Care
These are services you receive when you are not sick or injured with the intention of helping you stay healthy. Preventive care services include annual physicals, wellness screenings, and well-child care.
In-Network
In-network refers to providers or healthcare facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower costs to the insurance companies with which they have contracts.
Out-of-Network (OON)
Services received by a non-network service provider are considered out-of-network.
Out-of-network healthcare and plan payments are subject to separate deductibles and OOPM. When you receive care from an OON provider, you may need to submit the claim on your own.
Certificate of Coverage / SPD
The Certificate of Coverage / SPD is a summary of the master plan document. It is available for members through their own secure member website. If changes are made to the master plan, amendments to the Certificate of Coverage / SPD will be posted.