Healthcare terms & FAQs  | Blue Shield of CA

Common healthcare terms and FAQs

The terms and acronyms for health insurance can be confusing. Here are some common words to know as you explore coverage options:

Frequently asked questions (FAQs)

  • What is the California Premium Subsidy?

    California is the first state to provide its residents who did not previously qualify for financial help (because they earned more than 400% of the Federal Poverty level) with state-funded premium assistance, called the California Premium Subsidy. For those eligible, the California Premium Subsidy sets a limit on how much one pays for their medical premium based on a percentage of their annual income. The amount of premium assistance that Californians can qualify for depends on age, household income and size, and the cost of affordable health care coverage in their region. State and federal premium assistance are only available for medical plans purchased through Covered California.

    See the Federal Poverty level income table and read more about the California Premium Subsidy and the individual mandate.

  • How do I qualify for the California Premium Subsidy?

    To be eligible for the California Premium Subsidy, you must meet the following criteria:

    • Earn 600% of the Federal Poverty Level or less, and
    • Affordable coverage (the second-lowest cost silver plan) in your region costs more than your premium contribution level set by the government

    If you find out you may be eligible, contact us to learn about your options at (888) 273‑0010.

  • How does health insurance work?

    A health insurance policy determines the types of medical services or benefits you are covered for, which doctors you can see, and what hospitals you can visit. Your plan also determines what you pay for care and services. 

    After purchasing a health plan, you can then visit a doctor or hospital in the Blue Shield of California network. A network is a group of doctors, hospitals, and healthcare providers that work with a health plan like Blue Shield. That means you only have to pay a certain amount for healthcare services instead of the full cost. By using in-network doctors and hospitals, you can keep your costs lower. 

    Health insurance is for preventive and event-based care – meaning you don’t have to wait until you’re sick to see a doctor. Preventive services like annual exams and flu shots are available to you at no additional cost. 

     

  • What do I pay monthly?

    You’ll pay a fixed monthly rate for your health insurance policy. The amount depends on the plan you choose, where you live, and the age of each person on the policy. The lower your plan’s monthly rate, the more you typically pay when you see the doctor, and vice versa. Identifying how often you see a doctor can help you choose the right plan for you.

    Depending on your household size and income, you may be eligible for financial assistance through Covered California to lower your plan’s monthly rate or even your costs for medical care.

     

  • What do I pay when I see a doctor?

    Your bill for visiting the doctor will depend on the reason for your appointment and your plan’s benefits. Some services have a copay (a fixed dollar amount) and other services have coinsurance (a fixed percentage amount). When you pay a copay or coinsurance, Blue Shield of California will pay the rest of the charges for your visit. You should check to see if your health plan has an annual deductible, which is the amount of money you pay for services before the coinsurance and health plan begins paying for them. A high deductible could affect what you pay at each doctor’s visit.

    To protect you and your family from unexpected costs, most plans have an annual out‑of‑pocket maximum. Once you reach the out-of-pocket maximum, your health plan covers 100% up to the allowed charges for most covered medical services.

Common healthcare terms

  • Allowed charges

    The approved amount Blue Shield will pay for a service or benefit. If your doctor charges more than what’s allowed by your health insurance policy, you may be responsible for the difference.

  • Benefits or covered services

    The medically necessary services and supplies covered by Blue Shield.

  • Coinsurance

    A fixed percentage of the cost of your services that you’re responsible for. This is usually after you’ve met your deductible.

  • Copayment

    A fixed amount you pay for benefits such as doctor’s visits or any wellness services. This is usually after you’ve met your deductible if your plan has one.

  • Deductible

    The amount you pay each calendar year for most benefits before Blue Shield begins to pay. Some benefits, such as preventive care, are covered before you meet your deductible.

  • HMO

    A health plan where you choose a primary care physician (PCP) who treats you regularly. This includes preventive visits and referrals to specialists. You’ll need to see only other doctors or specialists in your PCP’s medical group. There is no coverage for services received from doctors who are outside your PCP’s network. 

  • Network

    A group of providers – including hospitals, doctors, specialists and other healthcare providers – that have agreed with Blue Shield to provide benefits for a specified amount.

  • Out-of-pocket maximum

    The most you are required to pay in combined deductible, copayment, and coinsurance amounts for all of the covered services each year.

  • PPO

    A health plan in which members can choose to see any provider in the PPO provider network without a referral. Members also have the freedom to use non-network providers for most services if they are willing to pay a higher share of the cost.

Page last updated: 10/01/2020