Learn More About PPO deductibles, copayments and coinsurance.
What are billed charges?
Billed charges are the amount charged or billed by your healthcare provider for the services/supplies you received. Not all provider charges will be paid by your health insurance plan.
What are allowable charges?
Allowable charges are the maximum amount payable to you under your health insurance plan for a particular service. Contracted providers have agreed to accept this amount as payment in full. For example, if the provider charges $100 for a service and Blue Cross and Blue Shield of Kansas City (Blue KC) pays $80 as the allowable charge, the provider cannot ask the member to pay the remaining $20. Keep in mind, however, that some health insurance plans have coinsurance. In those cases, members are required to pay a percentage of the allowable charge. For specific details about your plan, review your Blue KC certificate, which outlines your payment responsibility.
What is a provider write-off?
Providers who have entered into a contract with Blue KC have agreed to accept a specific payment amount for each of their services. This is often a discounted amount versus what these providers might normally charge. The provider write-off is the difference between what they normally charge and the discounted amount specified in our agreement with that provider. We refer to this as the “provider write-off.” Ultimately three things determine what Blue KC pays a provider:
- The amount of your copayment and/or coinsurance
- The amount of your deductible that has been satisfied
What is a copayment?
A copayment, or copay, is the dollar amount that you pay to a provider at the time you receive a service. For example, you might pay a $30 copay each time you visit your allergy doctor. The copay amount is defined in your Blue KC certificate, which outlines your responsibilities for health insurance plan payments.
What is a deductible?
A deductible is the amount that you are responsible for paying annually for healthcare services. You pay coinsurance after you’ve met your deductible. Exceptions are outlined in your Blue KC certificate, which lists the exclusions related to your health insurance plan.
How is my deductible calculated?
Each payment you make for covered healthcare services you’ve received from your providers such as a physical exam (not counting copays that you make at the time of your visits) counts toward your deductible. Once Blue KC processes the claims we receive from your providers showing the payments that you have made for covered healthcare services, we apply those payments toward your deductible.
What services and charges do not count toward the deductible?
When you pay for certain services, those payments may not count toward you meeting your deductible. For details about exclusions, review your Blue KC certificate.
What is coinsurance?
If your plan has coinsurance, you will have to pay a portion of the allowable charge for a covered service. You pay coinsurance after you’ve met your deductible. For details about your payment responsibilities, please review your Blue KC certificate.