How Health Plans Work
Costs, benefits, savings, deductibles. Watch 3 short videos and understand your healthcare better.
3 things to know
Use in-network providers for greatest savings, otherwise if you use out-of-network providers you may be responsible for additional costs.
While this is general information about how plans work, get your personalized plan details.
Services can be covered, but that doesn’t always mean covered at 100 percent. They are subject to copay, coinsurance, and deductible.
Health plan basics: Benefits
In-network providers offer greater savings
Health plans contract with a specific group of doctors, hospitals, and other healthcare providers to offer services and supplies at a discounted price—that’s your plan network.
Because you pay part of the costs for your medical care, it's important to know that you pay less when you get care from providers in your plan network. Care from providers that are not in your plan's network:
- May cost more,
- May not apply toward your plan deductible,
- Or may not be covered by your plan at all.
Premera offers a variety of plan options that come with different networks. Some are broad, with providers across the country. Other Premera plan networks are narrower, with providers only in a region.
That means a doctor who is in-network for one Premera plan might not be in-network for your plan. Often providers will say they bill or accept Premera, so it's important to confirm that they are in your plan network.
The name of your plan network can be on the front of your member ID card. Sign in to your online account and use Find Care to search for providers in your plan network.
How your health plan works
You haven't reached your $1,500 deductible yet
Office visit costs:
$100
You pay:
$100
Your plan pays:
$0
Preventive care is covered in full on most plans.
You reach your $1,500 deductible. Co-insurance begins
Office visit costs:
$100
You pay 20% (coinsurance):
$20
Your plan pays 80%:
$80
You had a few doctor visits and reached your deductible. Your plan now begins paying most of your qualified medical costs.
You reach your $5,000 out-of-pocket limit
Office visit costs:
$100
You pay:
$0
Your plan pays:
$100
You have seen the doctor several times and have paid $5,000 out of pocket this year. Now your plan will pay the full cost of your qualified medical costs this year.
Health plan basics: Costs
Here’s another example of how health plan costs work
Let's say your health plan has:
| $2,500 deductible For in-network services |
You pay for most care and medical services until you’ve met your deductible of $2,500. |
|---|---|
| $35 copay For office visits |
For each office visit, you pay a $35 copay whether or not you’ve met your deductible. |
| 30% Coinsurance |
After you’ve paid your $2,500 deductible for the plan year, your plan starts paying 70 percent of the cost of covered care. You pay 30 percent, which is your coinsurance. For example, if the total cost of an office visit was $200, you’d pay $60 coinsurance ($200 x .30 = $60). Your plan would pay $140 ($200 x .70 = $140). For an office visit, you’d also pay a $35 copay. |
| $6,350 Out-of-pocket maximum |
After you’ve paid $6,350 in your deductible, copays, and coinsurance, you’ve met your out-of-pocket maximum. Your plan pays 100 percent of your covered care for the rest of the plan year as long as you use in-network providers. |
Note
These are example numbers. Please look at your plan benefit booklet for your exact deductible, coinsurance, copay, out-of-pocket maximum, and other information on amounts you’re required to pay. You can also search your specific provider network.
Health savings account (HSA) basics
Definitions
Allowed amount
This is the amount providers have agreed to accept as full payment for covered healthcare services and supplies. It’s important to use an in-network provider. Otherwise, out-of-network providers can bill the difference between the rate Premera would pay an in-network provider for the service and what the provider billed. The remaining balance, which is the patient’s responsibility, is called balance billing.
Coinsurance
The percentage of healthcare costs you’re responsible for. After you meet the deductible, you and Premera will share the cost of care until you’ve reached the out-of-pocket maximum. For example, if you have 20 percent coinsurance, your health plan would pay 80 percent of the bill and you would be responsible for the remaining 20 percent until your out-of-pocket maximum is reached.
Copay
Similar to coinsurance, but it’s a fixed amount paid at the time of service rather than a percentage of the cost. If you have a $50 copay, you’d pay $50 at your doctor visit.
Covered
Your health plan offers payment for a service, although not necessarily at 100 percent. The cost is subject to copay, deductible, network, and plan limits.
Deductible
The amount you pay for covered health care services in a plan year before your health plan starts to contribute to your cost of care. With a $2,000 deductible, for example, you pay the first $2,000 of covered services.
Out-of-pocket maximum
When the amount you’ve spent on deductible and copay or coinsurance meets your out-of-pocket maximum amount, your health plan will pay for your eligible medical expenses for the rest of the plan year. This is the most you’ll have to pay out of pocket for your covered care. Your monthly premiums do not count toward your out-of-pocket maximum.
Preapproval
A requirement to obtain prior authorization, also known as preapproval, from your health plan carrier before recieving healthcare services to prove that the services are medically necessary.
Premium
The monthly payment you or your employer pay for your health coverage. This is what you pay to have medical coverage. The amount doesn’t count toward your deductible or out-of-pocket maximum.
Personal funding accounts
Your plan might come with options for accounts that allow you to set aside pre-tax dollars for qualified medical expenses or dependent care.
Frequently asked questions
How do I find doctors in my network?
Sign in to your online account and use Find Care to get personalized results, including providers in your network.
If you do not sign in, you can use Find Care, and select the network yourself. Get the name of your network from the front of your member card.
What happens if I use an out-of-network provider?
Out-of-network providers can charge additional amounts for services that don’t apply to your annual out-of-pocket maximum.
For example, if you have a procedure with an in-network provider who usually charges $200, but the allowed plan amount is $150, they can only charge $150. The doctor writes off the other $50. If you have the same procedure with an out-of-network provider, the provider can bill you the additional $50. If your Premera plan has out-of-network benefits, it will only cover the allowed amount that they would pay a contracted provider.
How do I pay my doctor bill?*
An in-network provider will bill Premera on your behalf and then the provider will bill you any costs that are remaining, including deductible or coinsurance. If you see an out-of-network provider, you may submit a claim to Premera. We will process it within 30 days of receipt. Premera explains how a claim has been processed in the form of an explanation of benefits statement (EOB).
The EOB is not a bill. It simply explains how your plan benefits apply to that particular claim. It includes:
- Date you received the service
- Amount billed
- Amount covered
- Amount Premera paid
- Any balance you’re responsible for
- How much has been credited toward your deductible
You will receive a separate bill from your healthcare provider for any payment owed. We recommend comparing that bill to your EOB, and then pay them directly.
*This information is not applicable for members on an Individual or Family plan.