More Health Insurance Terms

  • 10% Discount - When your school district or bargaining group offers only the WEA Select Medical Plan(s) and one licensed HMO plan from one HMO carrier*, you pay the 10% discount rate for your WEA Select Medical Plan coverage; less money comes out of your paycheck.

    * Point-of-service or other plans not filed and approved as HMOs by the Office of the Insurance Commissioner do not qualify.

    Allowable Charge - The maximum amount that Premera pays for a covered service or supply is known as the “allowable charge.” If you use in-network providers, this means that the providers have agreed to accept this amount as payment in full after you have met your deductible, and any applicable copays and coinsurance. You will not be balance-billed if you use in-network providers.

    BlueCard - If you live outside Washington State or are traveling nationally, in Puerto Rico or the Virgin Islands and need medical care, the BlueCard Program enables you to seek services at discounted rates when using providers contracted with local Blue Cross Blue Shield Association plans. Use the phone number on the back of your Premera ID card for help finding a contracted provider.

    You also have coverage internationally. Although BlueCard Worldwide provides a network of contracting hospitals, it only provides referrals to doctors and other health care providers. Use the same phone number for this service.

    For more information, see the BlueCard section in your benefit book.

    Contracted vs Non-contracted Providers - Using an in-network provider—also known as a contracted provider—can help keep your out-of-pocket expenses down. An in-network provider accepts your plan’s “allowable charge” as payment in full for medically necessary services. An out-of-network, or non-contracted, provider does not have an agreement with us and may bill you for remaining balances over Premera’s allowable charge.

    Copay and Coinsurance - One way to help keep costs in check is to share them—you pay part and the plan pays part. That’s what the "co" means in the terms "copay" and "coinsurance."

    • "Copays" are a fixed dollar amount you pay each time you use certain services such as doctor visits; the plan picks up the rest of the cost. However, during the visit the doctor may perform other services such as lab and x-ray.
    • You have a "coinsurance" for services such as diagnostic lab and x-ray; you pay a percentage of the bill after your deductible and the plan picks up the rest. There is a ceiling, or "out-of-pocket maximum", on the coinsurance and medical copays you pay each year. Once you reach it, the plan will pay 100% of allowable charges for these services for the rest of the calendar year.

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    Deductible - Your “deductible” is a set amount that you pay each year before your plan pays for certain services such as hospitalizations, and lab and x-ray services. You meet this deductible once each calendar year.

    Out-of-pocket Maximums 

    • “Individual” and “family” deductibles, and
    • “Individual” and “family” out-of-pocket maximums

    Individual: Each person covered under the medical program has a deductible and out-of-pocket maximum that must be met for major medical services.

    Family: This maximum applies to families with three or more family members.

    • Family example 1: Deductible - If three people in a family of four meet their individual deductibles, then the fourth family member's deductible is considered to be met.
    • Family example 2: Out-of-Pocket Maximum - If three people in a family of four meet their individual deductibles and also their individual coinsurance amounts (Deductible + Coinsurance = Out-of-Pocket Maximum), then the fourth family member’s out-of-pocket maximum is also considered to be met.

    The out-of-pocket maximum does not include:

    • Premiums
    • Prescription drug costshares 
    • Care not covered by your health plan
    • Amounts you pay for non-covered services or services for which benefits have been exhausted, or
    • Amounts over the allowable charge

    Note: WEA Select EasyChoice Plans have a separate deductible and out-of-pocket maximum for medical services and prescription drugs. These costshares are calculated on a per person per calendar year basis.

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    Plan Maximums 

    • “Individual” and “family” deductibles, and
    • “Individual” and “family” out-of-pocket maximums 

    Plan Year vs Calendar Year - Your benefits and rates change as of the plan year (November 1 through October 31).

    Deductibles, out-of-pocket maximums and benefit limits are calculated on the calendar year (January 1 through December 31)

    Preventive Care - All WEA Select Medical Plans provide coverage for in-network preventive services such as colonoscopies, diabetes education and some preventive drugs at no cost to you. View the list of preventive services to learn more

    Preventive vs Diagnostic Lab & X-ray Services - Preventive services are covered in full when you use an in-network provider.

    • Preventive services and associated lab and x-ray are listed here 
    • Diagnostic lab and x-ray services are provided when you have a medical diagnosis—a sore throat that requires a throat culture, a broken arm that requires an x-ray and lab work not called out on the preventive list. These services are covered differently, under your Diagnostic Lab and x-ray benefit

    Find more in your benefit book.

    Primary vs Secondary Health Plan - When you have more than one health plan, your plans work together to provide benefits as follows:

    • The primary plan provides benefits as if you had no other coverage.
    • Benefits through a secondary plan may be reduced because of coordination of benefits rules that ensure the combined payments of all the plans don’t exceed the covered health costs.

    Provider Network - Your ID card lists which provider network (Heritage or Foundation) is used by your WEA Select Medical Plan. The "Plus 1" after the provider network indicates that your plan provides an out-of-network benefit option.

    • In-Network services are always covered at the higher benefit level – meaning lower out-of-pocket costs to you.
    • Out-of-Network (Plus 1) services are covered at the lower benefit level – resulting in higher out-of-pocket costs.

    Which provider network does your plan use?

    • Heritage - WEA Select Plans 2, 3, and EasyChoice A and B
    • Foundation - WEA Select Plan 5, EasyChoice C, and QHDHP 

    Use the "Find a Doctor" top tab on this page to see your provider's network status.

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    QHDHP - The WEA Select Qualified High Deductible Health Plan (QHDHP) meets the IRS definition of a high deductible health plan. Designed for use with a Health Savings Account (HSA), the plan provides benefits after paying the deductible/coinsurance*. Coverage does not begin until after the deductible has been met.

    *In-network preventive care and some preventive drugs are the exception. See the Medical Benefits page for the summary of benefits and a list of preventive services and drugs that are covered at no cost to the enrollee.

    Subscriber - The employee who is eligible for the benefits of the medical care plan. The employee and dependents eligible for coverage are also referred to as "enrollees." 

    Summary of Benefits and Coverage (SBC) - Mandated by Federal Health Reform, the SBC for each WEA plan provides a detailed look at how it covers services. The glossary appears at the end of each SBC. Definitions for concepts such as copayments and coinsurance are included. In addition, Premera continues to provide side-by-side plan comparisons of the most commonly used services for all the plans. These side-by-side comparisons can be found on the Medical page.

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