The better you know your health insurance, the more informed decisions you can make about your health when choosing a plan this Open Enrollment season. A good place to start is with some of the industry\u2019s most common terms related to choosing your plan and using your benefits.<\/p>\n\n\n\n
Choosing the right plan<\/u><\/strong><\/p>\n\n\n\n Exclusive Provider Organization (EPO)<\/strong><\/p>\n\n\n\n A type of health plan where you receive healthcare services only from doctors, hospitals, and specialists in your plan\u2019s network. There is no out-of-network coverage except for emergency services. Non-emergency services received out-of-network are not covered.<\/p>\n\n\n\n Health Savings Account (HSA)<\/strong><\/p>\n\n\n\n An HSA allows you to pay for qualified medical expenses with tax-free money. To qualify for an HSA, you must have a Qualified High Deductible Health plan (QHDHP). In general, you can use the money in your HSA to pay for deductibles, copayments and other expenses not covered by your health plan, like dental or vision expenses. If you don\u2019t use all the money in your account by year-end, don\u2019t worry. The money rolls over from year to year.<\/p>\n\n\n\n Health Maintenance Organization (HMO)<\/strong><\/p>\n\n\n\n A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.<\/p>\n\n\n\n High Deductible Health Plan (HDHP)<\/strong><\/p>\n\n\n\n A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more healthcare costs yourself before the insurance company starts to pay its share (your deductible). Certain plans that meet IRS guidelines are called qualified high deductible health plans. QHDHPs can be combined with an HSA, allowing you to pay for certain medical expenses with money free from federal taxes.<\/p>\n\n\n\n Open Enrollment<\/strong><\/p>\n\n\n\n Open Enrollment is a yearly opportunity to change your health coverage. In most cases, you can only make changes during open enrollment or when you have experienced a specific qualifying event like the birth of a child or new marital status. Open Enrollment is your opportunity to review your insurance and spending accounts benefits coverage and make choices for the upcoming calendar year. The 2026 Open Enrollment Period is November 1, 2025 \u2013 January 15, 2026. Learn more about\u00a0Open Enrollment<\/a>.<\/p>\n\n\n\n Preferred Provider Organization (PPO)<\/strong><\/p>\n\n\n\n A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan\u2019s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.<\/p>\n\n\n\n Utilizing Your Benefits<\/u><\/strong><\/p>\n\n\n\n Allowable Charge<\/strong><\/p>\n\n\n\n The maximum dollar amount Blue KC allows contracting providers to charge for a particular service. The difference between the billed charge and the allowable charge usually represents your discount for being a Blue KC member; we\u2019ve negotiated these allowable charges with the healthcare providers in our networks. For example: Your doctor charges $100 for an office visit and $80 is the allowable charge, so the doctor will apply a $20 discount to your bill.<\/p>\n\n\n\n Coinsurance<\/strong><\/p>\n\n\n\n The percentage (for example, 20%) you pay for a covered healthcare service, typically after you\u2019ve paid your deductible.<\/p>\n\n\n\n Copayment<\/strong><\/p>\n\n\n\n The fixed amount (for example, $25) you pay for a covered healthcare service, usually when you receive the service. The amount can vary, depending on the provider and the type of healthcare service.<\/p>\n\n\n\n Deductible <\/strong><\/p>\n\n\n\n The amount you pay for applicable services received before your health plan begins to pay. For example, if your deductible is $1,000, your health plan will not pay for covered services until you\u2019ve paid $1,000 toward your covered healthcare expenses. Once you meet your deductible, your health plan will begin to pay a portion of your covered healthcare expenses.<\/p>\n\n\n\n Explanation of Benefits (EOB) <\/strong><\/p>\n\n\n\n It looks like a bill, feels like a bill, but an EOB is not a bill. It\u2019s the statement Blue KC sends you after you\u2019ve received services from a healthcare provider. The EOB lists several things, including the services you received, the amount your plan covers, and the total amount billed to you.<\/p>\n\n\n\n In\/Out-of-Network<\/strong><\/p>\n\n\n\n An in-network provider is a doctor, hospital or other healthcare professional that has an agreement with Blue KC to provide services to plan members for a set rate. Generally, Blue KC will pay a larger percentage of your healthcare costs when you use an in-network provider.<\/p>\n\n\n\n An out-of-network provider is a hospital, pharmacy, physician or other medical service provider that does not have a network contract with Blue KC to provide healthcare services to members. Blue KC Individual & Family Plans do not cover services received from out-of-network providers, except for emergency and urgent care services. Some unanticipated out-of-network care is subject to protections established in the No Surprises Act. For more information on when and how these protections apply, visit bluekc.com\/caa\/members\/<\/a>.<\/p>\n\n\n\n Out-Of-Pocket Maximum<\/strong><\/p>\n\n\n\n Most benefit plans include a maximum dollar amount you may spend in a calendar year. If the total dollar amount you have paid in deductibles, coinsurance and copayments reaches this maximum amount, then Blue KC will pay 100% of the allowed charges for the remainder of the year for covered services.<\/p>\n\n\n\n Premium<\/strong><\/p>\n\n\n\n The amount you pay monthly for your health plan.<\/p>\n\n\n\n Have more questions? Give us a call at 888-890-6912. We\u2019re available Monday \u2013 Friday from 8a.m. \u2013 5p.m.<\/p>\n\n\n\n <\/p>\n\r\n\t\t\tWas this helpful?<\/h3>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t