How does health insurance work?

1.

Premium

Your health insurance premium is the amount you pay to have your health insurance plan and is used to help fund medical care. You, and your employer if you're on an employer-sponsored plan, pay it on a regular basis — usually monthly, quarterly or annually.

2.

Allowed amount

This is the maximum amount your health plan will pay for covered health care services. It may also be called an “eligible expense,” “payment allowance,” or “set rate.”

3.

Coinsurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if your health plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20 percent would be $20. The health plan pays the rest of the allowed amount. (See deductible and allowed amount.)

4.

Copay

Copayment, or copay, is a fixed amount (for example, $15) you pay for a covered health care service, usually due at the time you receive the service. The amount can vary by the type of covered health care you receive. For example, a copay for routine care from a primary care provider (PCP) may be lower than the copay for care from a specialist.

5.

Deductible

The amount you owe for health care services your plan covers before your health plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible. The deductible may not apply to all services. For example, almost all preventive exams are covered at no cost to you if you have health insurance — regardless if you've met your deductible or not.

6.

Balance billing

Balance billing happens when a provider bills you for the difference between the provider’s charge and the allowed amount (the amount your health insurer has set for the service). For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. An in-network provider cannot balance bill you for covered services.

7.

Out-of-pocket limit

The most you pay during a policy period (usually a year) before your health plan begins to pay 100 percent of the allowed amount. This limit never includes your premium, balance-billing amounts or charges for health care your health plan doesn’t cover.

8.

Health insurance network

A health insurance network is a group of doctors, specialists, facilities and other medical providers who have an agreement with Wellmark to provide health care services. Some common network types are:

• HMO, which stands for health maintenance organization. This type of plan gives you access to specific doctors and hospitals, and typically only covers out-of-network care in the event of an emergency. Learn more about HMO networks.
• PPO, which stands for preferred provider organization. This type of plan offers broader access to care. Your costs will be lower if you stay in-network, but PPO network plans typically pay a portion of out-of-network care.
• POS stands for point of service. These plans are a combination of HMO and PPOs.
• EPO stands for exclusive provider organization. This type of network offers coverage for local services in the plan's network and geographic service area.

Shopping for health insurance? See Wellmark’s health insurance plans for individuals, employers, Medicare and travel medical plans.

9.

In-network providers

An in‑network provider has a contract with your health plan to provide services at a specific rate. Check your coverage documents to see if your health plan has a “tiered” network. You may pay more or less, depending on the provider.

Please note:

• If you are on an HMO plan, you will want to see a provider within the Wellmark network to ensure your services are covered.
• If you are on a PPO plan, you can see any provider you want. However, you will pay less if you see a provider in Wellmark's provider network. Out-of-network providers may bill you for the difference in their charge and what Wellmark pays, resulting in higher costs than you expected.

1.

Explanation of Benefits (EOB)

Every time you receive care, you’ll receive an Explanation of Benefits from your health insurance company. EOBs explain how your benefits were applied to the medical services you received and what you have left to pay. An EOB is not a bill. Your EOB will include your provider's name, the services you received, the amount your provider charged for the service, the amount your insurance paid and the amount you are responsible for paying. Wellmark members receive a paper EOB in mail and can view them online by logging in to myWellmark. When you view your EOB online, you can also sort by date, provider or patient to easily review your spending and services.

2.

Coverage manual and Summary of Benefits and Coverage (SBC)

The best way to know what benefits and resources your plan includes is to check your coverage documents. Your coverage documents, such as coverage manual or SBC, provide an in-depth explanation of everything your plan does or does not cover. It also includes information about other services included with your health plan at no extra cost. These include health support programs like case management and pregnancy support or resources like virtual care and BeWell 24/7^®.

3.

myWellmark

The myWellmark member portal helps Wellmark members stay updated on their plan benefits and usage, easily manage their health care spending and find care. With myWellmark, members can:

• Access their ID card
• Find a provider in their plan’s network
• View detailed claims information
• Securely message Wellmark customer service with questions or concerns
• Track their medical expenses
• Get estimates of how much their care might cost before they receive care.

Members can log in online or download the app.