Employee Sponsored:
Most people buy health insurance through an employer or a “group” plan. This can be your employer or your partner/spouse’s employer.
Understanding Health Insurance
The basics of health insurance
77% of Americans are confused by health insurance terms. These terms are universal when it comes to healthcare coverage. Understanding them can help prepare you when choosing a plan and knowing how to use it.
Health insurance helps you pay for medical care when you have an illness, injury or seek preventive services that are important checkpoints to keeping you healthy. There are several types of plans you can choose and each one has a different amount that you and the insurance company will pay. You can purchase health insurance for yourself or you can get a family plan and cover your spouse, domestic partner and children.
Preventive visits
Vaccinations
Specialist visits
Hospitalization
Behavioral health/mental services
Pregnancy, maternity and newborn care
Prescription drugs
Emergency room visits
Lab work
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When do you get health insurance?
The time you select/register for a plan is called Open Enrollment Period (OEP). For Medicare, it’s called the Annual Election Period (AEP).
Although Open Enrollment can occur at any time of the year, it typically occurs at the end of the calendar year. You will choose your plan to start January 1 the following year. For Medicare and the Annual Election Period, you choose your plan between October 15 through December 7.
You can enroll outside of Open Enrollment Period (OEP) during a Special Enrollment Period (SEP) with the following situations (also called a qualifying life event):
Changing marital status
Starting work with a new employer
Losing other health insurance coverage
Moving to a new state
Having a child or adding a dependent
Qualifying for Medicaid or CHIP (Children's Health Insurance Program)
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Where & how do you get health insurance?
Individual Plans:
Individual plans are available to everyone through the government marketplace (healthcare.gov) established by the Affordable Care Act.
You can also purchase individual plans through privately owned health insurance companies.
Government Programs:
Medicare is a federal program designed for people who are 65 and older and young people with disabilities.
Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded by the federal government.
Parents or guardians can keep children (dependents) under the age of 26 on their health insurance plan.
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Why do you need health insurance?
Health insurance is used for basic wellness in addition to managing chronic conditions, men’s/women’s health, pediatric care and other high risk health issues. It allows you to join with a larger group of people (your company or groups of individuals) and pool your money together to spread out the risk of large healthcare costs.
Even as a completely healthy individual it is important to get routine check-ups to help prevent future health issues from arising and to prevent future medical bills that could get expensive.
Planning for the unexpected and having health insurance can give you security when an emergency arises.
In-network vs. out-of-network
Your network consists of a group of doctors, hospitals and other healthcare professionals who have agreed to provide medical services to members of a healthcare plan for a certain price. Arkansas Blue Cross creates a comprehensive statewide network to ensure strong coverage for you, while making sure every medical provider and facility agrees to certain discounts that make care more affordable for you.
In-network
Doctors, hospitals and other healthcare providers that have agreed to provide medical services at set prices with your health plan. This will be the discount shown when you get an explanation of benefits for a visit.
Out-of-network
Doctors, hospitals and other providers who have not agreed to set prices with your health plan.
What does this mean?
To save money, you will typically choose an in-network provider because Arkansas Blue Cross has negotiated what their services will cost. Out-of-network providers usually charge more. If you receive care from a doctor or hospital that is out-of-network you won’t get the negotiated price (meaning you will pay more out-of-pocket).
Cost of health insurance
Health insurance works by splitting the cost of healthcare between an individual and the insurer to pay the provider. If you hit your maximum out-of-pocket amount for a specific year, your insurer will pick up 100% of the cost.
Prior to receiving healthcare, you will show proof of insurance to your provider. This will tell them what kind of coverage you have and how to bill or charge you for your visit. The amount you are billed depends on many things such as:
Plan type
Deductible amount
In-network or out-of-network care
Premium, copay, deductible, coinsurance and out-of-pocket maximum. These are all commonly used words in the world of health insurance that can be confusing. What do all these words mean and how do they work together?
Premium
Every month
You pay
$150
Copay
Sometimes referred to as a copayment, this is the fixed amount you pay, usually at the time of medical services. Some plans do not have a copay for visits*. Usually, copays are separate from and do not count toward your deductible amount. They do count toward your out-of-pocket maximum, which can help if you have high medical expenses during a calendar year. Your copay can vary, depending on the type of service you receive (for example, a copay for seeing a specialist may be more than a copay for a PCP visit. You also may have a copay with prescriptions.
In-network PCP visit
You pay
$40
Deductible
Deductible is the amount you pay for medical costs before your health insurance begins to make payments to providers for services. Your insurance provider will have certain things that are considered allowable charges to go towards your deductible. They also have different deductible amounts for in-network and out-of-network services
Example:
In-network specialist visit:
$100
Coinsurance
This is the percentage of the cost you are responsible to pay. Once you meet your deductible, your insurance begins to pay a majority of your in-network visits and you may pay 20% and they pay 80% (exact percentages depend on your provider and plan). Sometimes the health plan pays 100% of coinsurance once the deductible is met.
Example:
In-network hospital visit:
$500
Out-of-pocket-maximum
Most plans have an out-of-pocket maximum, meaning once you pay the set amount, your insurance will cover 100% of any further eligible healthcare expenses. The out-of-pocket limit includes your deductible, coinsurance and copay amounts. The out-of-pocket limit does not include premium payments or charges for services that are not covered.
For example, if your out-of-pocket maximum is $3,000, when you reach this amount, your insurance will cover everything else at 100%.
Example
In-network specialist visit:
$200
*Prices are to be used as an example and can vary. Figures are based on individual plans with no dependents.
Types of health plans
There are special accounts you can use toward medical expenses and prescription: health savings accounts (HSA), flexible spending accounts (FSA) and health reimbursement arrangements (HRA). These accounts let you save and use tax-advantaged money to cover qualified medical expenses. HSA accounts rollover year to year while FSA and HRA accounts must be used before the end of the year.
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Health Maintenance Organization (HMO)
With this plan, you choose a PCP who coordinates your care using doctors and hospitals that are in your plan’s network. If you need a specialist, such as a cardiologist, a referral from your PCP is required. Generally, an HMO won’t cover services from an out-of-network provider.
An HMO plan will usually have a lower monthly premium and deductible, but include coinsurance and copays.
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Preferred Provider Organization (PPO)
This plan allows you to manage your own care, with or without referrals from a PCP. You have a choice in which provider to see, although you’ll save money if you remain in network.
A PPO will likely have higher premiums than other types of plans, but lower copays and coinsurance.
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Point of Service (POS)
A POS is a combination of HMO and PPO. Like an HMO, you choose a PCP. But like a PPO, you can get medical care from both in- or out-of-network providers. You’ll pay less when you use a doctor or hospital in-network and more if you choose out-of-network.
A POS plan may require you to pay a higher premium and have copays, but most have no deductible for in-network services referred by your PCP.
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High Deductible Health Plan (HDHP)
This plan gives you the most control on how your healthcare dollars are spent. A HDHP has a higher deductible, but a lower monthly premium and a special HSA account to help you save money for healthcare expenses.
HDHPs typically have lower premiums, but you will pay more out-of-pocket for healthcare. Most HDHPs pay for several preventive care visits, but you will pay out-of-pocket for other types of care and prescriptions at the contracted amount set by your insurance and provider.
Member ID card
Arkansas Blue Cross will send you a member ID card once you’ve enrolled in your
plan and your coverage has started. This includes the essential information you
need to know about your coverage, payment amounts and customer service phone
numbers. Each provider you visit will need to make a copy of your ID card to
make sure they bill correctly. Always carry your ID card with you in your
wallet. You also have access to a digital ID card on
Blueprint Portal. Download the app to have your ID card anywhere you have your phone.
Your card may look slightly different than this example, depending on the
health plan you have.
Learn more about your ID card
For more information, select a number.
Disclaimer: Your card may look slightly different or have different information
1
Member ID number
Helps us identify who you are, the type of plan you have and how your claims are paid.
2
RX categories
Used by the pharmacy to determine what’s covered, apply your discount and file your claims
3
RX copay
How much you pay for your prescriptions depending on their type
4
Group number
Used to check your plan’s benefits
5
Deductible
How much you pay for medical expenses before the health plan begins to pay for some covered services
6
Copay
How much you pay for a doctor visit, depending on the type
7
Coinsurance
How much of your medical bill you must pay after meeting your deductible
8
Type of plan
Lets us know what kind of coverage you have
9
Suitcase
Represents access to national BlueCard® network (see Find Medical Care Quickly for more information)
Pharmacy
Prescription medications play an important role in your health and wellbeing. Your health plan typically includes pharmacy benefits that connect you to medications you need as easily and affordable as possible.
Helpful terms and definitions for understanding your pharmacy coverage:
Brand-name medication
A brand-name medication is usually owned by one company and is the first of its kind. They are patented usually for a period of time before other companies can make generic versions. The brand-name medication will commonly be more expensive than the generic.
Generic medication
A prescription drug that is required by law to have the same active ingredients, strength, dosage, form and administration as brand-name products. Generic medications usually cost less than a brand-name drug.
Independent pharmacy
A pharmacy that is owned and operated by an individual or small group, and are not affiliated with a major chain. They usually focus on personalized service and community engagement.
Maintenance Drugs
Prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medications. Examples include medications used to treat high blood pressure, asthma or diabetes.
Over-the-counter (OTC)
These are drugs that can be purchased directly at a pharmacy or store without a prescription. Common examples are medications like Ibuprofen (pain or fever) or Antihistamines (allergy).
Prescription (Rx)
A prescription is a written order from a healthcare provider that allows a patient to receive a specific medication. It usually includes the name of the drug, its strength, dosage amount, how often to take it, how it should be taken and if refills are allowed. The abbreviation for prescription is Rx and each prescription has its own unique number.
Prior Authorization
Depending on the prescription, you may need prior authorization. Having prior authorization means that before a prescription is filled, it’s reviewed for approval from your health plan to make sure the medications, tests or treatments you receive are clinically appropriate, safe and affordable.
Retail pharmacy
A pharmacy that fills routine prescriptions and sells over-the-counter medications. Some retail pharmacies may also offer services like health screenings and immunizations.
Specialty pharmacy
Specialty pharmacies fill more complex prescriptions that may require special care, cost more or need extra support from a healthcare provider. They focus on providing medications for chronic, rare or serious health conditions.
Step therapy
A type of prior authorization that requires a member to try a lower-cost option for a medication before a higher-cost option is considered.
Formulary and drug tiers
Different plans have their own set of prescription drugs they cover. This list is called a formulary.
When researching what medications are covered by your plan, you may see there are tiers. Drug tiers represent different levels of cost and can save you money on your medications. You pay the least for medications in tier 1, which usually are generic drugs.
Plans differ on the amount of tiers they have. An example of how a four-tier formulary might be structured:
Tier 1
Generic non-specialty drugs
Lowest plan member copay.
Tier 2
Preferred, brand-name products
Intermediate plan member copay.
Tier 3
All non-specialty, non-preferred, brand-name products
Higher plan member copay.
Tier 4
Specialty medications
Highest plan member copay.
Ancillary
What about the other stuff? Dental, vision, life and disability are all additional insurance products you can get with your health insurance. If you are getting your health plan through your employer, they will usually have options for you. There are individual options too through privately owned companies as well as government resources.
Health insurance is not just for people with chronic health conditions or expensive situations. Having health insurance gives you access to healthcare at a lower cost than if you were uninsured. Even if you do not have health issues you are aware of, taking advantage of preventive care can allow you to get ahead of unplanned circumstances and make sure you are maintaining your health. Now that you know a little more about the basics of health insurance, take that important first step by finding a PCP in Blueprint Portal (link to BP) and scheduling your annual wellness exam.
Have more questions?
Visit us online at arkansasbluecross.com or call the customer service number on the back of your ID card.