Understanding Health Insurance

Ever feel confused by your health care plans?

"What's a copay? A deductible? An out-of-pocket maximum? How does my plan work if I have to go to a doctor?" Use this easy guide for a better idea of how it works and get some peace of mind.

Preventive care

  • We cover 100% of the cost for yearly checkups, preventive tests and other things that keep you healthy.*

Copay (copayment)

  • When you see a doctor, most plans have you pay a certain amount to the doctor for the visit. It is a fixed dollar amount paid to your doctor.
  • This amount does not go toward your deductible or your out-of-pocket maximum.

Deductible

  • You pay this amount for covered services each calendar benefit year (January through December).
  • Covered services that would apply to the deductible may include labs, X-rays, anesthesia and surgeon fees.
  • Your deductible starts over (usually, but not always) each calendar benefit year.

Coinsurance

  • Once you've met your deductible, Anthem Blue Cross and Blue Shield starts paying a portion of claims. (Preventive coverage starts before the deductible is met.)
  • The health care bills that remain are shared between you and Anthem. This is called "coinsurance."
  • Anthem will pay between 50% and 100% of the bill.

Out-of-pocket maximum (max)

  • Every plan has an out-of-pocket maximum. The amount you pay in deductible and coinsurance are typically what make up your out-of-pocket maximum.
  • With some plans, you have to keep paying a copay for doctor's visits and prescriptions even after the out-of-pocket maximum is met.
  • Once you meet your out-of-pocket maximum, we pay 100% of covered services for the rest of the calendar benefit year. See your plan for details.

* The following preventive services, recommended by the United States Preventive Services Task Force, are covered at 100% when received in-network: well child care, immunizations, PSA screenings, pap tests and more. If you are on a grandfathered plan, your benefits may vary.

 

A plan in action

Health plan in actionJohn's health plan has the following benefits:

  • $30 copay for doctor visits.
  • $2,000 deductible.
  • 30% coinsurance (up to a limit of $3,000).
  • $5,000 out-of-pocket maximum.

After injuring his knee in a soccer game, John calls his doctor. He chooses a doctor in our network, which saves him the most money. By choosing network doctors and labs, John gets lower negotiated rates (meaning, discounted prices). This example explains what happened, what John paid and why it is important to have health insurance.

What happened What John paid
John visits the doctor Copay
Doctor visit cost (without insurance): $200
Anthem's negotiated rate: $140
Anthem pays: $110
John pays: $30
$30
Tests and treatments Deductible
The doctor orders an MRI of the knee.
MRI cost (without insurance): $1,500
Anthem's negotiated rate: $1,000
John pays: $1,000
$1,000
John's payment counts toward his deductible. Doctor recommends surgery
Doctor recommends surgery.
Hospital/Surgery costs (without insurance): $50,000
Anthem’s negotiated rate: $35,000
John pays: $1,000
Remaining cost of surgery: $34,000
$1,000
John’s payment satisfies his remaining deductible.
Surgery costs continued Coinsurance
Having met his deductible, John's coinsurance begins.
Coinsurance: 30% (30% of $34,000 = $10,200)
John pays: $3,000
Remaining cost of surgery: $31,000
$3,000
John has a coinsurance limit so he only pays $3,000 instead of $10,200.
Remaining surgery costs are paid Out-of-pocket maximum
Anthem pays: $31,000 $5,000
$2,000 deductible + $3,000 coinsurance
Note:
This example of a plan in action is for illustrative purposes only and actual benefits of the plan will vary.

 

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