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FAQ: Health insurance basics

A copayment, or copay, is the fee you pay when you see a doctor or get other services. You may pay a copay of $30 to see a doctor or $550 when you go to the emergency room.

The percentage you pay for some covered services. If your coinsurance is 20 percent, your health insurance company will pay 80 percent of the cost of covered services, and you will pay the remaining 20 percent. The amount you pay is typically not based on the full retail price of the service. It is based on a discounted rate negotiated by your insurance company with heath care providers like doctors and hospitals.

The amount you pay for your health care costs beyond your premium. This includes your deductible, copayments, and co-insurance fees.

A deductible is the amount you pay each year before your health plan starts paying for covered services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of the costs for the services you receive. Once you have paid this amount, your insurance will begin to pay a portion or all of your health care costs depending on the health plan.

If you choose a health plan with a high deductible, you may have a lower monthly premium. If your plan has a high monthly premium, your deductible amount may be lower. Learn more about deductibles.

All of our health plans will have an embedded deductible for family coverage. In a plan with an embedded deductible, the family deductible and out-of-pocket maximum apply when more than one person is covered under a plan. A covered family member only needs to meet his or her individual deductible before the health plan begins to cover costs. Once the family deductible is met, then all covered family members will receive plan benefits.

This is the maximum amount that you will have to pay under your plan. Any care for covered services you get after you meet your out-of-pocket maximum will be covered 100 percent. The out-of-pocket maximum varies by plan and can be found in your benefit brochure. The out-of-pocket maximum does not include premiums or charges for covered services that are not Essential Health Benefits (EHBs).

There are several things you can do to help ensure you have affordable health insurance.

  • Use health care providers in your plan’s network.
    You can save money on health insurance costs by choosing health care providers within your health plan’s network. You can use the Find a Doctor tool to find out if your current primary care physician (PCP), health care specialists, and facilities are in the network.
  • Choose generic prescription drugs.
    You can also make your health care more affordable by choosing generic prescription drugs over name-brand prescription drugs. Generic drugs offer the same benefits of name-brand drugs – but at a lower cost.
  • Take advantage of preventive care.
    You can save money and prevent some serious illnesses by actively maintaining your health and scheduling regular preventive care appointments. The Affordable Care Act (ACA) now requires health insurance plans to cover preventive care without charging a copayment or coinsurance, even if you have not yet met your plan’s annual deductible. View a full list of free preventive health services.
  • See if you are eligible for financial help.
    You may be eligible for financial assistance (also called a subsidy) to help pay for your health insurance. Use our health insurance subsidy calculator to see if you qualify for financial assistance.

You may also qualify for free or low-cost health insurance for uninsured children and low-cost health coverage for uninsured adults. View available low-income health plans offered by Independence Blue Cross to learn more.

The Care Cost Estimator provides members with estimated out-of-pocket costs for health care services. This feature allows members to retrieve cost data for more than 1,600 inpatient, out-patient, and diagnostic services among the physicians and hospitals in our network.

This tool is available for all commercial products. To access the Care Cost Estimator, log into the member portal at www.ibx.com/login and access the Care Cost Estimator tool by clicking on the My Care tab and clicking Estimate Cost of Care.

A PCP is the doctor you see for most of your health care needs. HMO plans require you to choose a PCP, who will refer you to a specialist when needed. PPOs and EPOs do not require that you choose a primary care physician. To find a PCP, use our Find a Doctor tool.

Yes. Once you are a member, it’s easy to change your PCP. Simply login to ibx.com to make the change, or call 1-844-BLUE-4ME (or 1-844-258-3463, TTY: 711). PCP changes become effective on the first day of the following month.

A specialist provides medical care for certain conditions in addition to the treatment provided by your primary care physician (PCP). For example, you may need to see an allergist for allergies or an orthopedic surgeon for a knee injury. Under an HMO plan, you need to obtain a referral from your PCP to receive benefits for care provided by a specialist. Under our PPO and EPO plans, you never need a referral to see a specialist.

If you have an HMO plan, your family doctor (or PCP) will need to write you a referral before you see other network providers, such as a dermatologist. No need to pick up a piece of paper, our referrals are done electronically, so in most cases you can get a referral simply by calling your PCP’s office.

Preventive care includes services that help you stay healthy. They may also detect some diseases in the early stages. Flu shots, mammograms, colonoscopies, COVID-19 vaccines and boosters are examples of preventive services. For more information on preventive services, visit our preventive care page.

A pre-existing condition is any condition, illness, or injury for which medical advice or treatment was recommended or received before a person obtains health insurance. Examples include diabetes, heart disease, and cancer. As part of the Affordable Care Act (ACA), no one can be denied health insurance due to a preexisting condition.

Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.

Therefore, you cannot be denied coverage because of pre-existing conditions. You also cannot be charged more due to a pre-existing condition or gender.

This may also be called preapproval or pre-authorization. Basically, you may need additional approval from your health plan before you receive certain tests, procedures, or medications. It’s a way to make sure the services you’re getting are safe and effective. Learn more about preapproval/precertification requirements.

Durable medical equipment includes, but is not limited to, the following: hospital beds, crutches, canes, wheelchairs, walkers, peripheral circulatory aids, cervical collars, traction equipment, physiotherapy equipment, oxygen equipment, and ostomy supplies. You should always check with both your provider and Independence Blue Cross to determine whether an item is considered to be durable medical equipment.

Your health care coverage is considered in-network when you use a provider who participates in our network of more than 60,000 doctors and 180 hospitals. For HMO plans, it’s the Keystone Health Plan East network. For PPO plans, it’s the Personal Choice® network which gives you access to see doctors in-network across the country, plus you have the option to visit doctors out-of-network at a higher cost. To see if a provider or hospital is considered in-network, use our Find a Doctor tool.

Your health care coverage is considered out-of-network when you visit a doctor or hospital that does not participate in our network. With HMO and EPO plans, you only have coverage for in-network providers, while PPO plans allow you the freedom to see both in- and out-of-network providers.

Urgent care centers are stand-alone clinics where board-certified doctors treat illness or injury requiring immediate medical attention. You can use these centers when your doctor is not available immediately and your illness or injury is not life threatening, such as a cut requiring stitches or continual nausea. Care in an urgent care center will cost you less than the same care in a hospital emergency room. For conditions that feel life threatening, such as severe shortness of breath or chest pain, sudden or unexplained loss of consciousness, severe abdominal pain, or a cut or wound that won’t stop bleeding, seek the care of the closest emergency room. Find a participating urgent care center.

A retail clinic is a space within a pharmacy or other retail store that is staffed by nurse practitioners. You can use these clinics when your doctor is not available and your injury or illness is minor, such as a sore throat, earache, or skin rash. Care at a retail clinic will cost you less than the same care in a hospital emergency room.

Please note that if you go to a retail clinic in a Walgreens store, and your prescription coverage uses the Preferred Pharmacy Network, you will need to go to another pharmacy in order to have your prescription covered by your health plan. The Preferred Pharmacy Network, used by all Proactive, Silver, and Bronze plans, includes over 50,000 pharmacies, including most major chains and local pharmacies. CVS is part of the Preferred Pharmacy Network; Walgreens is not. Find a participating retail clinic.

An HSA, or health savings account, helps you save money for health expenses, tax-free. You don’t pay taxes on the money you put in, the money you take out if used for qualified medical expenses, or any money you earn on the account. The IRS determines what qualifies as a qualified medical expense, which includes your out-of-pocket costs (copays, deductibles, coinsurance) along with some services not covered by a health plan, such as LASIK surgery.

A Health Reimbursement Account is a tax-advantaged account that is typically paired with a high-deductible health plan to help you pay for qualified medical expenses not covered by your plan. Because an HRA account is owned and funded by an employer, it does not go with you if you change plans or jobs.

A Flexible Spending Account is a tax-advantaged account that allows you to pay for qualified medical expenses not covered by your plan, such as copays, deductibles, coinsurance and certain services. An FSA is typically funded by you, as an employee (but your employer can fund as well), and does not need to be paired with a health plan. Any unused funds left over at the end of the year are returned to your employer.

The Find a Doctor tool allows you to search for doctors within the Independence Blue Cross network.

When you search for a doctor, you will need to select the plan network. You will then be able to see which doctors are in and out-of-network for that plan.

If you have an HMO plan, you are only covered for doctors and hospitals within the HMO network. With a PPO plan, you are covered for doctors and hospitals both in- and out-of-network. If the doctor or hospital you choose is out-of-network, then you may have to pay a higher out-of-pocket cost for your health service.

An online website where you can compare and buy health plans. Some states have their own Marketplace. Others let the federal government operate their Marketplace. At this time, Pennsylvania uses a state-based exchange called Pennie.

HIPAA stands for Health Insurance Portability and Accountability Act. It is a law that ensures member’s health information is protected. Members can request to have their health information released to a specific person(s) or have their information delivered in a specific format (i.e. email vs. mail). If you would like to designate a family member, friend, etc. to receive your health information when they contact your health plan, you can fill out a Personal Authorization or Authorization to Release form. These forms are located at www.ibx.com/login in our Resource Center.

If you have any additional questions about HIPAA, contact Customer Service at the phone number on the back of your ID card. Customer Service Representatives are available Monday through Friday, 8 a.m. – 6 p.m. (EST).