Insurance Basics

VICTOR: I'm Victor, and I'm meeting with a Blue Cross and Blue Shield customer advocate to discuss... questions to ask my doctor. I just changed my primary care doctor. Do you have any recommendations on getting to know them?

BCBS ADVOCATE: When it comes to your primary care doctor, maintaining a good relationship can be an important part of keeping yourself healthy. Communicating fully with your doctor can help eliminate any concerns you may have and promotes good health.

VICTOR: It can be a little scary talking to my doctor when I don't understand medical terms or know what questions to ask.

BCBS ADVOCATE: It starts with being open with your doctor about any medications you're taking and your medical history. Don't be shy. The more they know, the better they can treat you. From there, you can discuss any health concerns you have.

VICTOR: I'll definitely keep that in mind. I've always had knee issues, and I'm afraid I might need surgery. I've never had one, so I don't know what to ask.

BCBS ADVOCATE: Your primary care physician will make some recommendations on how to address your knee issues. This might include referring you to a specialist like a sports medicine doctor or orthopedic surgeon. Either will help you make a good diagnosis and recommend appropriate treatment.

VICTOR: OK, that's good to know.

BCBS ADVOCATE: When you follow up with an orthopedist or physical therapist, make sure you ask about appointments or lab procedures, let them know about any medications or additional vitamins you take, and ask whether or not you'll have to change your diet or physical activity.

VICTOR: That's not bad. What about my health coverage? Is there anything I need to do if surgery is recommended?

BCBS ADVOCATE: Yes, you can call Blue Cross and Blue Shield to find out if the procedure needs pre-authorization. If it does, your doctor will need to complete that process before your surgery.

VICTOR: This is a lot to remember.

BCBS ADVOCATE: Ask your physician and their staff about reaching out for any follow-up questions you might have. They're professionals who will provide any information you need and put you at ease.

VICTOR: OK, great. I feel a lot better now. Thank you.

BCBS ADVOCATE: You're welcome.

NARRATOR: For more information, call the number on your member ID card or visit our website at BCBSMT.com.

JOSEPH: Hi, my name is Joseph and today I'm meeting with a Blue Cross and Blue Shield customer advocate to talk about.....issues with my claim. I got a bill for my doctor and it doesn't look right to me. How can I check if it's correct?

BCBS ADVOCATE: This happens sometimes. The first thing you want to do is check your explanation of benefits also known as an EOB. That's a document you get from Blue Cross and Blue Shield after your claim is finalized. It breaks down each medical visit by how much your doctor has charged, what your plan covers, and how much you may owe your doctor. Carefully look it over to make sure the provider name, patient name, date of service and other details are all what you expect.

JOSEPH: What if I make a mistake?

BCBS ADVOCATE: Get in touch with Blue Cross and Blue Shield so we can review what was submitted and help answer your questions.

JOSEPH: Okay.

BCBS ADVOCATE: I also recommend calling your doctor's office and asking them to check the information they may need to resubmit your claim if there were errors.

JOSEPH: All right. Now what if my EOB shows my claim wasn't approved?

BCBS ADVOCATE: If you think your claim was denied in error you may be able to appeal the decision. Check your explanation of benefits or benefits booklet to learn how that works.

JOSEPH:  This is great information, thank you.

BCBS ADVOCATE: I'm glad I could help.

SPEAKER: For more information call the number on your member ID card or visit our website at BCBSMT.com

JOSEPH: Hi! My name is Joseph and today I'm meeting with a Blue Cross and Blue Shield customer advocate to talk about... understanding health plans and costs. I'm trying to budget for my family's health care but I'm not sure how to figure out what costs I'm responsible for. Deductibles, coinsurance, premiums, I have to admit I don't really get how they work. Can you help me?

BCBS ADVOCATE: The first cost to understand is your premium. It's an ongoing cost you pay to have health coverage. It's usually done once a month but you could have a different payment timeframe.

JOSEPH: Okay. When I go to the doctor it seems like I'm not always getting charged the same amount. What's that about?

BCBS ADVOCATE:  Well there could be a few reasons for that. Many plans cover preventive care with no added cost to you, so if you went in for a wellness checkup you may not know anything for that visit. A copay is a flat fee that you pay upfront. The copay depends on your plan, the type of provider you see, and whether they're in your plans network. For the sake of this conversation let's say that under your plan it's a $30 copay for doctor's visit.

JOSEPH:  Okay, that makes sense but when I had blood work done I got a bill for the whole service. Why is that?

BCBS ADVOCATE: A lot of plans have a deductible that applies to certain services. For example if your plan has a $1,000 deductible for lab work and x-rays you would pay 100% of the cost up to $1,000 before your plan
begins to pay for those services.

JOSEPH:  So what happens after I paid the $1,000?

BCBS ADVOCATE: Then you are responsible for coinsurance. The coinsurance is the amount you pay after your deductible is spent. It's usually a percentage. As an example let's say you've already met your deductible then later in the year you have an x-ray that has a payment of $400. If your coinsurance is 10% you'd owe $40 for the x-ray. Co-pays are paid whether your deductible is met, unless your service is not subject to cost sharing.

JOSEPH: Okay, so my premium is what I pay each month. My copay is a flat amount I pay for the office visit and my coinsurance is a percentage I pay for other services after the deductible.

BCBS ADVOCATE: You've got it! Be sure to look at your plan details for your deductible and how copay and coinsurance work.

JOSEPH: I'll definitely do that.

BCBS ADVOCATE: There's also a limit on how much you might have to pay each year. It's called an out-of-pocket maximum. After you reach this amount your plan will pay for most of the other covered expenses for the rest of the year.

JOSEPH: I like the sound of that. How much is my out-of-pocket max?

BCBS ADVOCATE: You can find out when you register and log into Blue Access for Members, under the my coverage tab. If you still have questions call the number on your member ID card.

JOSEPH:This has been so helpful. Thank you for meeting me.

BCBS ADVOCATE: My pleasure.

SPEAKER: For more information call the number on your member ID card or visit our website at BCBSMT.com.

VANESSA: Hi, I'm Vanessa, and I'm meeting with a Blue Cross Blue Shield advocate to find out, how I can save money on prescription drugs? I take a few prescription medicines and I'd like to save some money. Can you help me understand what effects the amount I pay for my medicine?

BCBS ADVOCATE: That's a good question. The first thing that effects what you pay is the type of health plan you have. Some plans have copays for prescriptions drugs those are flat amounts like $30, $50 or $75. Other plans have an amount that you pay toward health care costs before the plan benefits kick in. That amount is your deductible. On these types of plans after you pay your deductible you will usually split or share the cost of your drugs with your plan. Your portion is called coinsurance.

VANESSA: I'm pretty sure I have a copay, but I don't think it is always the same. Why would I have different copays?

BCBS ADVOCATE: There could be a few reasons for that. One is your plans prescription drug list. That is a list of drugs covered in your plan that is split into groups called tiers. Each tier may have a different cost

VANESSA:  So some medicine costs less than others.

BCBS ADVOCATE: Yes. Let's say your doctor prescribes a brand name drug and there is a generic version available. You could talk to your doctor to see if the generic would work for you. Generic drugs often cost less, so that is one way you could save money. Another way to save is to ask your doctor to prescribe drugs on your list if possible. Drugs not on your list may not be covered so they could cost more.

VANESSA: Does it matter where I get my prescriptions filled?

BCBS ADVOCATE: It could. When you choose a pharmacy in your network your medicine usually costs less than if you go out of network. You plan may also have a select group of pharmacies you can use to help you save even more when you use a pharmacy in this network.

VANESSA:  I'll look into that.

BCBS ADVOCATE: Just go to the prescription drug section in your Blue Access for Members account or log into myprime.com. You can see what drugs are covered in your plan, your copay, or coinsurance for prescriptions, your pharmacy network information and more. If you have more questions, you can call the pharmacy number on the back of your Blue Cross and Blue Shield ID card

VANESSA:  I've learned so much today. Thanks for helping me understand how I can save on my prescriptions.

BCBS ADVOCATE: I'm glad I can help

SPEAKER: Log into your Blue Access for Members account or visit the members services tab on our website at bcbsmt.com