Insurance 101: Talking health care

Insurance 101: Talking health care

January 8, 2020

health insurance word cloudChoosing a medical plan is the first step in making sure you have access to the care you need, when you need it. An essential second step is making sure you know what terms like deductible, copay and total network out-of-pocket maximum mean so you can make fully informed decisions about your health care.

What is a primary care provider?

A primary care provider (PCP) is the medical professional you choose to treat and coordinate your health care needs. He or she is usually the first person you call (unless it’s an emergency) to take care of you when you are sick, or guide you if you need more care. Your PCP can also help you stay up to date with yearly exams, immunizations and health screenings. Every HealthSelect of Texas® and Community First Health Plans participant must choose a PCP to get the highest level of benefits (that is, in-network benefits).

What is an in-network provider?

All health plans offered through the Texas Employees Group Benefits Program (GBP) use doctors, hospitals and other health care professionals that are part of what’s called a “provider network.” If you visit a provider outside of your plan’s network, you will likely have to pay more for your care. In some cases, you may have to pay the full cost. The best way to find in-network providers is by going to your plan's website.

HealthSelect of Texas and Consumer Directed HealthSelect participants can log in to Blue Access for MembersSM, the online participant portal, for a personalized search based on your health plan. (Note: You can search for an in-network provider without logging into Blue Access for Members if you prefer.) If you are enrolled in HealthSelect of Texas and you do not choose a PCP by the end of your grace period (see the definition of “grace period” below), you will get out-of-network benefits for any services you get, even if your provider is in-network.

What is a deductible?

A deductible is how much you have to pay out of pocket for health care before your health plan starts to pay for any covered services, except in-network preventive care, in a year. All GBP health plans except Consumer Directed HealthSelectSM have a $50 per person, per year prescription drug deductible. (Consumer Directed HealthSelect has a combined prescription drug and medical deductible.) In-network preventive services are covered at 100% before you meet your annual deductible. (Members of the HealthSelect plans can learn more about covered preventive care services. HMO members should check with their plans to find out more about preventive care.)

HealthSelect of Texas, HealthSelect Out-of-State and Consumer Directed HealthSelect plans have a deductible for out-of-network medical care. Consumer Directed HealthSelect and HealthSelect Secondary also have deductibles for in-network medical care, but the deductible for out-of-network care is higher.

The HMOs don’t have an out-of-network deductible, but you’ll pay 100% of the cost for any out-of-network care you get, except emergency care.

What are copays?

When you see your PCP or other health care professionals, you often have a copay, which is a set dollar amount you must pay for certain covered health services, usually at the time you get the service. For example, HealthSelect of Texas has a $25 copay per visit to your in-network PCP for non-preventive care. So if you see your PCP for a sore throat, you will pay $25 at your visit.

What is coinsurance?

Coinsurance is the percentage of your plan’s allowable amount you must pay for some services, after you've met your deductible, if you have one. (See definition of “allowable amount” below.) For example, if the plan’s allowable amount for a lab test is $100, and your coinsurance is 20%, you are responsible for paying $20. Your health insurance plan pays the other $80. If your HealthSelect plan has a deductible, and you haven't met that deductible, you will pay the full $100. If you're in an HMO and go out of network for non-emergency care, you will pay the full $100.

What is a total network out-of-pocket maximum?

There is a limit for how much you will have to spend on your in-network health care costs in a calendar year. This is called the total network out-of-pocket maximum. This maximum helps protect you from catastrophic health care costs. Your deductible, copays and coinsurance for in-network covered health services and prescription drugs apply to the total network out-of-pocket maximum. After you meet this limit, the plan will pay 100% of the allowable amount for covered services provided by an in-network provider or facility. All non-Medicare Advantage GBP health plans have the same total out-of-pocket maximum for covered in-network health and prescription drug costs. The total out-of-pocket maximum resets on January 1 for HealthSelect of Texas, HealthSelect Out-of-State, HealthSelect Secondary, Consumer Directed HealthSelect and HMO plans.

What is a referral?

dad, son and doctorA referral is a written order submitted to your health plan administrator from your PCP for you to see a specialist. If you are enrolled in HealthSelect of Texas, you need to get a referral for most services before you can get medical care from anyone except your PCP. If your PCP decides that you need to see a specialist, he or she will need to submit a referral to BCBSTX before your visit. If you see a specialist without a valid referral on file with BCBSTX, you will pay more because your visit will be considered out-of-network. In most cases, a referral is good for 12 months. (Referrals are not required for the HealthSelect Out-of-State, Consumer Directed HealthSelect or HealthSelect Secondary. Referrals are not required for HMO plans–except Community First Health Plans, which does require referrals to see specialists.)

What is a prior authorization?

A prior authorization is a review process to determine whether certain services are covered. A prior authorization confirms that a provider’s plan of treatment is the most appropriate level of care for your medical situation.

You need prior authorization for certain covered health services before you receive them. Your PCP and other in-network providers are responsible for getting prior authorization before they provide these services to you. If you choose to get certain covered health services from out-of-network providers, you are responsible for getting prior authorization from BCBSTX before you get these services.

What is an allowable amount?

The allowable amount is the maximum amount the plan will pay for a health care service. In the HealthSelect plans, allowable amounts are contracted between BCBSTX and providers who agree to participate in the HealthSelect network.

Remember: it pays to stay in network! If you get services from an in-network provider, you are not responsible for the difference in cost between the allowable amount and the amount the provider bills. For example, you see an in-network specialist who bills $150 for a service. The allowable amount is $100. You will pay $40 and HealthSelect of Texas will pay $60. You are not responsible for the additional $50 that is over the allowable amount.

If you are enrolled in Consumer Directed HealthSelect, you will have to pay the full allowable amount for a service until your out-of-network deductible is met before benefits are paid by the plan. The out-of-network deductible is higher than the in-network deductible. And, as shown in the example above, you don’t have to pay the difference between the billed and allowable amount for in-network providers.

For certain out-of-network services, you may be responsible for paying the out-of-network provider any difference between the amount the provider bills you and the amount paid by the plan. This is also referred to as balance billing.

If you're in an HMO, there is no allowable amount because you have to pay 100% of the cost for non-emergency out-of-network care.

What is the HealthSelect of Texas grace period?

If you enroll in HealthSelect of Texas and do not select a PCP at the time you enroll, you have a 60-day grace period from the effective date of your coverage to choose a PCP. During the grace period, before you choose a PCP, in-network benefits will apply when you visit any in-network PCP. In-network benefits will also apply when you visit an in-network specialist with a valid referral from an in-network PCP. 

Once you name a PCP, the grace period ends, and all services must be coordinated through your PCP. If, after you choose a PCP, you get services from a provider without a valid referral from your PCP on file with BCBSTX, out-of-network benefits apply. If you do not choose a PCP by the end of your grace period, you will get out-of-network benefits for services you get, even if your provider is in-network.

Need more details?
Watch this video that discusses common terms related to health care cost sharing in your health plan.

To find deductibles, copays, coinsurance and total network out-of-pocket maximum amounts for the HealthSelect plans, view the Health Plans Comparison Chart.


Want to test your medical insurance terms knowledge? Test yourself with this crossword puzzle. For best results, print the puzzle. Do your best and then come back to check your answers!
If you have questions about how specific services are covered on your HealthSelect plan, visit the Publications and Forms page of the HealthSelect of Texas website. You’ll find a Master Benefit Plan Document for your HealthSelect plan. You can also call a BCBSTX Personal Health Assistant. BCBSTX Personal Health Assistants are trained to help you and your covered family members make the best use of your health insurance benefits, which may save you money. Call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday-Friday 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. CT.

If you have questions about how specific services are covered in the HMOs:
  • Community First Health Plans: (877) 698-7032 (TTY: (210) 358-6262), Monday-Friday 8:30 a.m. - 5 p.m. CT
  • Scott and White Health Plan: (800) 321-7947, Monday-Friday, 7 a.m. - 7 p.m. CT