Definitions You Should Know

The better you know your health insurance, the more informed decisions you can make about your health. A good place to start is with some of the industry’s most common terms related to choosing your plan and using your benefits. 

Choosing the right plan 

Exclusive Provider Organization (EPO) 

A type of health plan where you receive healthcare services only from doctors, hospitals and specialists in your plan’s network. There is no out-of-network coverage except for emergency services. Non-emergency services received out-of-network are not covered. 

Health Savings Account (HSA) 

An HSA allows you to pay for qualified medical expenses with tax-free money. To qualify for an HSA, you must have a qualified high deductible health plan (QHDHP). In general, you can use the money in your HSA to pay for deductibles, copayments and other expenses not covered by your health plan, like dental or vision expenses. If you don’t use all the money in your account by the end of the year, don’t worry. The money rolls over from year to year. 

High Deductible Health Plan (HDHP) High Deductible Health Plan (HDHP) 

A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more healthcare costs yourself before the insurance company starts to pay its share (your deductible). Certain plans that meet IRS guidelines are called qualified high deductible health plans. QHDHPs can be combined with a Health Savings Account, allowing you to pay for certain medical expenses with money free from federal taxes. 

Open Enrollment 

Open enrollment is a period of time – usually but not always occurring once per year – when you may change your health coverage. In most cases, you can only make changes during open enrollment or when you have experienced a specific qualifying event like the birth of a child or marriage. Open enrollment is your opportunity to review your insurance and spending accounts benefits coverage and make choices for the upcoming calendar year. You should actively enroll during open enrollment to ensure your benefits meet your needs. 

Utilizing Your Benefits 

Allowable Charge 

The maximum dollar amount Blue KC allows contracting providers to charge for a particular service. The difference between the billed charge and the allowable charge usually represents your discount for being a Blue KC member; we’ve negotiated these allowable charges with the healthcare providers in our networks. For example: Your doctor charges $100 for an office visit and $80 is the allowable charge, so the doctor will apply a $20 discount to your bill. 

Coinsurance 

The percentage of costs of a covered healthcare service you pay(for example, 20%) typically after you’ve paid your deductible. 

Copayment 

The fixed amount (for example, $25) you pay for a covered healthcare service, usually when you receive the service. The amount can vary, depending on the provider and the type of healthcare service. 

Deductible  

The amount you pay for applicable services received before your health plan begins to pay. For example, if your deductible is $1,000, your health plan will not pay for covered services until you’ve paid $1,000 toward your covered healthcare expenses. Once you meet your deductible, your health plan will begin to pay a portion of your covered healthcare expenses. 

Explanation of Benefits (EOB)  

It looks like a bill, feels like a bill, but an EOB is not a bill. If you have a health plan, it’s the statement you get from your insurance company after you receive services from a healthcare provider. The EOB lists several things, including the services you received, the amount of cost your plan covers, and the total amount billed to you. 

In/Out-of-Network 

An in-network provider is a doctor, hospital or other healthcare professional that has an agreement with Blue KC to provide services to plan members for a set rate. Generally, Blue KC will pay a larger percentage of your healthcare costs when you use an in-network provider. 

An out-of-network provider is one that does not have a contract with Blue KC. Blue KC Individual & Family plans do not cover services received from out-of-network providers, except for emergency and urgent care services. Some unanticipated out-of-network care is subject to protections established in the No Surprises Act. For more information on when and how these protections apply, visit bluekc.com/caa/members/. 

Out-Of-Pocket Maximum 

Most benefit plans include a maximum dollar amount spent in a calendar year. If the total dollar amount you have paid in deductibles, coinsurance and copayments reaches this maximum amount, then Blue KC will pay 100% of the allowed charges for the remainder of the year for covered services. 

Premium 

The amount you pay monthly for your health plan. 

Have a health plan question or want to enroll in a Blue KC health plan? Please contact Blue KC Customer Service.