Health Maintenance Organization (HMOs)

The term HMO stands for Health Maintenance Organization. HMOs are regarded as a managed health care system, which provide prepaid medical services with little out of pocket expense. With an HMO plan, the subscriber will be required to see a Primary Care Physician (PCP) that is in network with their HMO plan. These plans have networks of medical providers, and subscribers must seek treatment from these providers. There are no out of network benefits under an HMO plan. Some HMO plans may also require your Primary Care Physician give you a referral in order to see a specialist. Because these types of plans have more restrictive networks, subscribers will generally have lower premiums and low deductibles under these plans.

Preferred Provider Organizations (PPOs)

The term PPO stands for Preferred Provider Organization. These plans are an arrangement under which a group of independent doctors and hospitals become preferred providers in an area. PPO plans offer more flexibility and choices when it comes to choosing your doctor or hospital. Like HMOs, PPOs also have a network of providers. However, there are fewer restrictions on seeing providers who are not in network. Under a PPO plan, you will also usually have the benefit of seeing a specialist without a referral from your Primary Care Physician. Because PPO plans are more flexible, premiums tend to be higher, and it is common to have a deductible.

Point of Service (POSs)

Point of Service Plans (POS) are a hybrid plan that combine features of PPO and HMO plans. These plans are designed so the member can choose (at the point of service) which part of the plan they would like to utilize. If the subscriber stays in network with this plan, they will have HMO benefits. If the member sees an out of network provider, they will be responsible for the out of network rates. Blue Cross Blue Shield of North Carolina offers a variety of Point of Service health plans. CLICK HERE to generate a custom quote and discover your plan options.

What do these plans have in common?

HMO’s, PPO’s and POS plans all have provider networks. A network refers to the list of doctors, hospitals, labs, and other providers that are contracted with the health plan. The difference in these plans network options is the size of the network, and whether or not the plan offers out of network benefits. Each of these types of plans also offer coverage for emergency services both in and out of network.

At NC Health Plans, we understand that making decisions within the Health Insurance market can be confusing. Blue Cross Blue Shield of North Carolina offers a variety of health plans for both under 65 and Medicare shoppers. Give us a call to speak with one of our professional agents and discover what health plan will work best for you or your family.

For more information on North Carolina Health Insurance coverage, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our experienced and professional agents.

Coinsurance is the percentage of covered medical expenses that you pay after you’ve met your deductible. Coinsurance is usually listed as a percentage. For example, if your plan lists coinsurance at 20% of covered medical expenses after you’ve met your deductible, then the plan pays 80% of covered services, and you pay 20% until you reach your coinsurance maximum.Coinsurance maximum The coinsurance maximum is the total amount of coinsurance that you’re required to pay for covered medical services in a plan year. Once you reach the coinsurance maximum, your plan usually covers 100% of all covered services for the remainder of the benefit period. Under a traditional health plan, you would continue to pay any copayments for covered services, such as office visits or prescription drugs. Under a high-deductible health plan, your covered medical services would be paid 100%.

Out-of-pocket maximum

Your out-of-pocket maximum is the maximum amount you would be required to pay in a plan year for covered medical expenses. With a high-deductible health plan, this amount is usually the total of your deductible plus your coinsurance maximum. Knowing the definitions of some common terms associated with health insurance may help you make better decisions about choosing a plan that’s right for you.

Premium

A premium is the periodic payment made to your health insurance company to keep your health insurance policy active. Premiums are separate from other health insurance out-of-pocket costs, such as copayments, deductibles and coinsurance.

Copayment

A copayment is the flat-rate fee that you pay to your provider for office visits or to the pharmacy for prescription medications. Many high-deductible health plans don’t have copayments. Instead you pay the negotiated rate for the visit, until you meet your deductible.

Deductible

A deductible is the amount you pay each year for covered medical expenses (such as medical care or prescription drugs) before your health insurance begins paying toward those expenses

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our professional agents. Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC). You may qualify for a 15% healthy lifestyle discount if you are in excellent health. Call us for details.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

As consumers, we are demanding more medical services than ever before. And the cost of these services is going up. These increased costs are passed on to employers in the form of increased premiums. Insurance companies work with employers to adjust services offered, as well as co-payments and deductibles, to minimize the impact of rising costs.

Take time to understand your health plan — it can help save healthcare dollars for you and for all Americans. For example, many health plans offer a reduced co-pay if you choose FDA-approved generic prescription drugs, so you pay less. Because the average total cost of a generic drug is three times less than the brand name, it helps keep costs down in your health plan.

Understanding the basics of how health insurance works and how to make the most of your own health plan can help keep healthcare affordable for everyone.

The content of this post is from BlueCross BlueShield Association’s article “Coverage Basics: How Health Insurance Works”

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

Earn prizes for taking an active role in your health.
Physical activity can help reduce the risk of cancer, heart disease, diabetes and other health conditions. That’s why we created Blue PointsSM, our physical activity and wellness incentive program available exclusively for BCBSNC members.

Just 30 minutes a day of physical activity or participation in wellness activities earns points toward prizes like electronics, sports equipment, clothing and more!* Collect points and select prizes from our four Blue Points prize levels (B, L, U, and E). Special prizes are available for children ages 6 – 12 through Blue Points for KidsSM.

Frequently asked questions
Q: Why is Blue Points changing?

A: The new Blue Points will include more activities and opportunities to earn points and all-new prizes to win.

Q: Will current Blue Points users have immediate access to the new Blue Points when it begins January 1, 2009?

A:Yes.

Q: When is the last day to redeem points for a current prize?

A:December 31, 2008. Members are encouraged to redeem points as soon as possible. Current points will not carry over to the new Blue Points program. At least 250 points are needed to redeem for a prize.

Q: If current points are not used by December 31, 2008, will those points carry over to the new Blue Points program?

A:No. All participating members will start with a zero balance on their Blue Points account beginning January 1, 2009.

Q: What is Blue Points?

A:Blue Points is a program from Blue Cross and Blue Shield of North Carolina that is designed to give eligible BCBSNC members a reason to get physically active and take an active role in their health.

Q: How does Blue Points work?

A:  Register online at www.bcbsnc.com to receive an activity log by mail.  Choose “Manage Your Blue Points” from My Member Services menu.  Record one entry per day of at least 30 minutes of physical activity or participation in a specific wellness activity.  When you reach 250 points, select your prize from level B and submit your activity log.  Repeat to complete levels L U and E. Then start again at level B.
Q: Are all BCBSNC members eligible for Blue Points?

A:No. Certain government and special accounts tied to specific contract terms are not eligible at this time. If you are a current BCBSNC member, log in or call the customer service number of the back of your BCBSNC ID card to learn if you are eligible.

Q: Can I earn Blue Points even if my physical activity isn’t strenuous?

A:Yes, activities such as walking, gardening and even washing your car are Blue Points worthy. As long as you’re staying active and getting your body moving for at least 30 minutes, it counts!

Q: If I exercise more than 30 minutes in one day, or exercise and participate in a wellness activity on the same day, can I earn more than 10 points for that day?

A:No. Regardless of how long you exercise or if you also participate in a wellness activity on the same day, you can only earn 10 points per day.

Q: If I earn a prize, can I donate it?

A:Yes. When you earn a prize, you’ll have the opportunity to donate it. Throughout the year, BCBSNC teams up with different organizations to receive donated prize. We partner with a variety of groups working to improve the quality of life in North Carolina.

Q: If I’m not already a BCBSNC member, whom can I contact for more information about the Blue Points discount program and becoming a BCBSNC member?

A:If you receive health insurance coverage through your employer, please contact your group benefits administrator and tell them about your interest in BCBSNC and the Blue Points program. If you buy insurance directly, call 1-800-324-4973 for more information about BCBSNC consumer products that include the Blue Points program.

Q: I am very interested in the Blue Points discount program, but I am not currently a BCBSNC member. Can I buy just Blue Points?

A:The Blue Points discount program cannot be sold separately. It is a value-added service we provide to our membership.

*The content in this post is provided by Blue Cross and Blue Shield of North Carolina.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC). You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

A deductible is the amount you must pay before the insurance company begins to pay any policy benefits. This is usually an annual amount per insured person, per calendar year.  Although typically there will be a maximum amount of deductibles you will have to pay per family in any given year.  For example, if your “per person” deductible is $500, and you have five people in your family covered under your health insurance, the maximum “family” deductible is usually three times the individual deductible or $1500.00 in this example.  Once three individuals have paid the $500 deductible, no more deductibles will apply to any member of the family for the remainder of the year. 

 Out-of-Pocket

This is the cost one would pay out of their own pocket. An out of pocket expense can refer to how much the co-payment, coinsurance, or deductible is. Also, when the term annual out-of-pocket maximum is used, that is referring to how much the insured would have to pay for the whole year out of their pocket, excluding premiums.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.

In-network:  Providers or health care facilities which 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 cost to the insurance companies with which they have contracts.

Out-patient: An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

COBRA: Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For more information, visit the Department of Labor.

Waiting Period

This is the time one would have to wait until certain health insurance coverages are available.

Lifetime Maximum

This is the most amount of money the health insurance policy will pay for the entire life. Pay attention to individual lifetime maximums and family lifetime maximums as they can be different.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.