All of our plans protect from severe financial hardship resulting from medical costs, but they have many different options and features.
Knowing which plan best suits your particular needs can help you save money and ensure that you have the right amount of health insurance coverage.
Would you rather have:
- Higher monthly payments but pay less out of pocket when you receive medical services?
- Lower monthly payments but pay more out of pocket when you receive medical services?
Look for these features when you review our plans.
- Blue Options HSASM provides coverage when you need it, at lower premiums.
- Blue Advantage® offers predictable copayments, reasonable premiums and deductibles so that you have a better idea of what you'll spend for medical services.
- Blue Advantage SaverSM gives you the kind of coverage you need if you don't need medical services that often - and at a low premium.
- Blue ValueSM provides coverage from a smaller, more streamlined network at some of the lowest premiums our plans offer.
Primary Care Office Visits
Ask yourself how often you (or someone in your family) see a primary care doctor for routine care (things like colds or minor injuries).
- Blue Options HSA doesn't require copayments for primary care office visits, but you'll pay more out of pocket for the visit until you meet your deductible.
- Blue Advantage offers predictable copayments so you can better estimate your financial costs when going for a primary care office visit.
- Blue Advantage Saver plans offer a variety of options for primary care office visits including copayments or paying more out of pocket until you have met your deductible.
- Blue Value plans have predictable copayments, so you'll know what to expect for primary care office visits. After four visits, some plans require you to pay more out of pocket until you have met your deductible.
Specialist Office Visits
Do you see a specialist? This would be someone like an allergist, a podiatrist or a cardiologist - basically any doctor other than your primary care doctor.
- Blue Options HSA keeps your monthly costs lower and allows you to save more if you don't need to see a specialist, but you'll pay out of pocket until you meet your deductible.
- Blue Advantage offers predictable copayments for specialist visits, plus there are no set limits on the number of times you can see a specialist.
- Blue Advantage Saver keeps your monthly costs lower and allows you to save more if you don't need to see a specialist, but you'll pay out of pocket until you meet your deductible.
- Blue Value plans keep your monthly costs lower by offering a variety of options for specialist office visits, including copayments and paying more out of pocket until your deductible is met.
Prescription Drug Coverage
Do you take prescription drugs regularly?
- Blue Options HSA involves paying more out-of-pocket costs for prescription drugs, until you meet your deductible. After you meet your deductible, you'll pay coinsurance.
- Blue Advantage offers copayments for prescription drugs (including $10 for generics) so you won't have to pay full price.
- Blue Advantage Saver plans all offer generic drugs at $10. Some plans offer a copayment for brand name drugs.
- Blue Value offers predictable copayments for prescription drugs (including $10 generics) after a separate prescription deductible is met.
Do you have a strong provider preference?
- Blue Options HSA offers a broad, deep network with lower, negotiated rates for visits to an in-network provider.
- Blue Advantage offers the same broad network and negotiated in-network rates as Blue Options HSA.
- Blue Advantage Saver provides members access to the same large network as Blue Options HSA and Blue Advantage.
- Blue Value offers a smaller, more streamlined network at a lower monthly premium.
NOTE: Please refer to each specific product page for more detailed information about each plan's benefits
® Mark of the Blue Cross and Blue Shield Association. SM Mark of Blue Cross and Blue Shield of North Carolina.
How It Works
How Deductibles and Coinsurance Work
All of our plans involve two important features: deductibles and coinsurance. Knowing how these work can help you better understand how health insurance works.
|You pay the full amount of your health care costs until you reach your deductible.||Once you've reached your deductible, BCBSNC shares your health care costs with you. This is known as coinsurance. The percentage you pay can range from 0% - 50%, depending on the plan you pick.||Coinsurance has a maximum. Once that coinsurance maximum is met, BCBSNC pays 100% of your covered health care costs for the rest of the year (except for copayments, which you'll still have to pay).|
Meet Fred: A real-world example
Fred's Insurance Plan (Blue Options HSA)
Coinsurance Maximum: $2,300
|Medical Services for the Year||
At this point, Fred has met his $2,700 deductible. He'll only have to pay 20% of future covered medical services until he reaches the coinsurance maximum for the year.
Fred has now met his coinsurance maximum for the year. He won't have to pay for any covered medical expenses for the rest of the year.
Figures are for illustrative purposes only. The examples provided in the chart relate to in-network service only. When using out-of network providers, in addition to deductible and coinsurance amounts, you may be responsible for the difference between the BCBSNC allowed amount and the provider's actual charge.
A prescription drug that has been patented and is only available through one manufacturer.
A formulary that only covers a list of specific prescription drugs and devices.
The percentage you pay for covered services after you meet your deductible.
The total amount of coinsurance you have to pay for covered services per benefit period. Deductibles, copayments and amounts exceeding the allowed amounts for covered services don't apply.
Money deposited into your health savings account (HSA). Contributions are tax-deductible and subject to annual limitations outlined by the IRS and based on your health plan's deductible.
A fixed-dollar amount that's payable at the time a covered service is provided.
The amount you pay for covered services before your health insurance plan pays for all or part of the remaining covered services.
A person (a spouse or a child) other than the subscriber who's covered under a health insurance plan.
The date when a health insurance plan's coverage begins.
A list of drugs covered by a health insurance plan.
Drugs which have the same active ingredient, strength and dosage form, and are considered by the Food and Drug Administration (FDA) to be therapeutically equivalent to brand-name drugs.
Refers to the use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee's out-of-pocket expense.
Services received when a member is admitted to a hospital or non-hospital facility as a registered bed patient for whom a room and board charge is made.
A smaller network of providers.
The facilities, doctors and other health care professionals who have agreed to offer care to a plan's members at a lower cost. Use of a provider that is not in our network can result in more member expense including higher deductibles, coinsurance and balance billing. However, in an emergency, in situations where in-network providers are not easily available, out-of-network benefits will be paid at the in-network benefit level. Not all BCBSNC health insurance plans have the same network of doctors.
Represents the type and level of office visit. Factors that determine the office visit category include complexity of the visit and the time spent with the provider.
A formulary in which all prescription drugs may be covered, subject to plan guidelines and limitations.
Services performed by a provider who has not signed a contract with the member's health plan to be part of a provider network.
Services received from a hospital or non-hospital facility while not an inpatient.
Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.
Point-of-Service (POS) Plan
A type of HMO health insurance product that offers a limited network of providers from which members can select. Members have incentive to use in-network providers to receive richer benefits, but may choose to use out-of-network providers at a higher out-of-pocket cost. Members who choose to use out-of-network providers are responsible for submitting their claims to BCBSNC in accordance with BCBSNC procedures.
A condition, disease, illness or injury for which medical advice, diagnosis, care or treatment was received or recommended within a specified time period prior to enrolling in health plan. Pregnancy and genetic information are not considered pre-existing conditions.
The amount paid to keep an insurance policy active.
Medical services related to the prevention of disease, provided by or upon the direction of a doctor or other provider.
Primary Care Physician (PCP)
A doctor selected by the member to be the first physician contacted for any medical problem. The doctor acts as the member's regular physician and coordinates any other care the member needs, such as a visit to a specialist or hospitalization.
A hospital, non-hospital facility, doctor or other provider, accredited, licensed or certified where required in the state of practice, performing within the scope of license or certification. All services performed must be within the scope of license or certification to be eligible for reimbursement.
A set of providers contracted with a health plan to provide services to the enrollees.
Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), or specific procedures (e.g., oral surgery).
Services provided for a condition that occurs suddenly and unexpectedly, requiring prompt diagnosis or treatment, such that in the absence of immediate care the individual could reasonably be expected to suffer additional health problems.
Frequently Asked Questions (FAQs)
Questions about our dental plans? Visit our Dental Blue FAQ.
- How do I know if I am eligible for health insurance coverage?
To be eligible, you must be:
- A North Carolina resident
- Under 65 years old and do not qualify for Medicare
- Discontinue any current health insurance as soon as your policy becomes effective
- When will my health insurance coverage begin?
Your coverage can begin on the 1st or the 15th of the month. If your online application is submitted by the 8th of the month, your coverage can begin as soon as the 15th of that same month. If your online application is submitted by the 22nd of the month, your coverage can begin as soon as the 1st of the following month. Requested effective dates may not be more than 60 days from the date you submit your application.
- How do I renew my health insurance coverage?
Your coverage is automatically renewed when you continue to pay premiums as they are due. BCBSNC must renew your policy unless we discontinue all policies like yours.
- When can I add or remove maternity from my policy?
The maternity rider option can be added to your policy when you first apply for coverage or during the renewal period, November 1 through 30, if the policy has been active for at least six months, or during a qualified life event, which is subject to review and approval. The individual to be covered cannot be pregnant at the time the addition is requested.
- If I visit a doctor or hospital outside the network, am I still covered?
Yes, you can see any doctor you choose, but remember: you save money when you visit a participating, in-network provider. Our network includes 91% of doctors in North Carolina and 99% of hospitals in North Carolina1. Our online provider search can help you find out whether your physician is in our network.
- Do all of your health insurance plans use the same provider network?
No. Blue Advantage®1, Blue Advantage SaverSM, and Blue Options HSASM share the same broad, deep network of providers. Blue ValueSM has a smaller, limited network of providers.
- What is the difference between an in-network provider and an out-of-network provider?
In-network providers are contracted with BCBSNC to provide services to members at discounted rates. Out-of-network providers aren't contracted, so their services usually cost more for members. Health insurance plans usually pay a lower percentage of out-of-network costs, which may increase member out-of-pocket expenses for those services.
- What are limited office visits?
Blue Advantage offers unlimited office visits that require a copayment. Some of our Blue Advantage Saver and Blue Value plans provide only a set number of copayment office visits. If a member goes beyond that set number of visits, they would have to pay out of pocket until they meet their deductible.
Blue Options HSA
- What is a Health Savings Account (HSA)?
A Health Savings Account (HSA) is a savings account that offers a tax-advantaged way for consumers to pay for their health care expenses2. Usually paired with a High Deductible Health Plan (HDHP), HSAs help consumers pay for current health expenses and save for future qualified medical and health expenses in retirement.
Contributions to an HSA are tax-deductible and distributions can be taken tax-free.3
You own and control the money in your HSA. You make the decisions on how to spend the money, within IRS guidelines for eligible expenses. The money in HSAs can be invested to take advantage of the potential for future growth. Investment options vary depending on who is managing the account.
- What is a High Deductible Health Plan (HDHP)?
A High Deductible Health Plan (HDHP) is a health insurance plan offering lower premiums in exchange for first dollar expenses going toward a deductible instead of copayments. The plan generally covers health care expenses after the deductible is met. You can also opt for varying coinsurance rates which can also affect your premium.
Preventative care is covered at 100% under an HDHP, and there is a cap on the out-of-pocket expenses you are responsible for during the year. HDHPs are frequently paired with HSAs to help you pay for expenses your plan does not cover. You must have an eligible HDHP to open an HSA.
- Can I have other health coverage in addition to my HDHP?
Yes, but to open and contribute to an HSA you cannot be covered by any plan other than eligible HDHPs, except for:
- Dental or vision coverage
- Long-term care coverage
- Accident/disability coverage
- Hospital Insurance Plan (HIP)-type coverage or disease-specific coverage
- Who can open and contribute to an HSA?
You must be covered by an eligible HDHP to open or contribute to an HSA.
An HSA is an individual account; you cannot open a jointly-held HSA. Multiple adults covered under a family plan may each open an HSA, but the collective total of both accounts may not exceed the family contribution maximum. Note: Although HSAs are individual accounts, the funds in the HSA can be used for your spouse, yourself or a dependent's eligible medical expenses.
A husband and wife enrolled in an eligible family HDHP can:
- Open an HSA in one spouse's name and contribute up to the family maximum. Those funds can be used to pay for medical expenses for anyone covered by the plan.
- Open individual HSAs and contribute to both, but the collective total of both must not exceed the family contribution maximum including any catch-up amounts. This may be an appealing option if you and your spouse are both eligible for catch-up contributions to an HSA after age 55, because each person's catch-up contribution must be made to their own account.
If you later unenroll from your HDHP, enroll in Medicare or become covered by a non-HDHP, you can keep your HSA and continue to use the remaining funds, but you can no longer contribute to it.
- What are the annual contribution limits for an HSA?
For 2013, the combined maximum contributions to your HSA, including any made by your employer, are:
- $3,250 if you have individual coverage
- $6,450 if you have family coverage
For 2014, the maximum contribution amounts are:
- $3,300 if you have individual coverage
- $6,550 if you have family coverage
If you turn age 55 or older during the plan year, you can add up to $1,000 more as a catch-up contribution. These amounts are valid as long as you are enrolled in qualified HDHP coverage for the entire tax year, or you enroll before the first day of December - meaning you have held at least one full month of HDHP coverage and then continue to maintain qualified HDHP coverage for the next 12 months (13 months total).
* Contribution limits are set by the IRS and are subject to change. Visit irs.gov for the most up-to-date information.
- Can I make contributions if I am not enrolled in an HDHP for the entire year?
If you are an eligible individual on December 1, it is possible to contribute up to the maximum annual limit for that year - even if you did not have eligibility for the full calendar year. This is known as the last month rule. Please note that the the IRS requires that you maintain HSA eligibility through December 31 of the following year (referred to as the "testing period").
If you do not remain HSA-eligible through the testing period, income taxes plus a penalty tax likely apply. For more information, please see IRS Publication 969, consult a tax advisor, or both.
- Can I open an HSA for my child?
No. You cannot establish separate accounts for dependent children, including children who can legally be claimed as dependents on your tax return. You can use your (or your spouse's) HSA funds to pay for your child's eligible medical expenses however, as long as the child is claimed as a dependent on your tax return.
- I turned 55 this year. Can I make the full catch-up contribution?
If you are an eligible individual on December 1, you can make the full catch up contribution regardless of when your 55th birthday falls during the year; however, if you did not have HDHP coverage for the full year, you must prorate your catch up contribution for the number of full months you had HDHP coverage. See IRS guidelines for information about prorating a contribution.
Each eligible individual covered by a HDHP, (i.e., the policy holder and his/her spouse, if both are at least 55) can make a catch-up contribution of up to $1,000 annually. Each spouse must have an HSA in their name to receive the catch-up contribution.
Note that the total contributions to all HSA accounts under a family plan must not exceed the family contribution maximum.
- What happens if I exceed the annual contribution limit?
Contributions made to your HSA that exceed the contribution limits are not tax-deductible. In addition, a tax penalty is imposed on excess contributions. You can avoid the penalty on excess contributions by withdrawing excess contributions before the last day prescribed by law (including extensions) for filing your federal income tax return for the tax year.
- I don't have earned income, can I have an HSA?
Yes. You do not have to have earned income to fund a Health Savings Account.
- Can someone other than the plan participant contribute to the participant's HSA?
Anyone can contribute to an HSA on your behalf including individuals not covered by the plan, i.e., extended family.
HSA contributions made by a family member on your behalf are tax-deductible by you when you are computing your adjusted gross income.
- When can contributions to an HSA be made?
Contributions to an HSA can be made at any time during the year in any increment, including:
- All at once at the beginning of the year
- All at once at the end of the year
- In equal amounts during the year
Contributions to an HSA for the current year can be made through April 15 of the following year.
- Can HSA funds be invested?
Yes. When your account balance reaches a certain amount, you can invest the excess funds. The same types of investments permitted for IRAs are allowed for HSAs, including stocks, bonds, mutual funds, and certificates of deposit. The investment options for your HSA account are determined by the investments offered by the HSA manager. BenefitWalletTM is the administrator of the HSA, and BNY Mellon or Mellon Trust of New England, N.A. is the custodian or trustee. After you purchase a BCBSNC HDHP, Benefit Wallet will send you a Welcome Kit with further information about the options for your HSA.
- What medical expenses can HSA funds be used for?
Review a list of eligible medical expenses
Review a list of noneligible medical expenses
HSA distributions are tax-free if used for eligible medical expenses as defined by Internal Revenue Code Section 213(d). Non-eligible distributions will be taxed as part of gross income and will incur a tax penalty. After age 65, the tax penalty is dropped, though the distribution is still treated as taxable income. Eligible medical expenses include doctor's office visits, pre-deductible amounts and coinsurance.
- Are claims incurred prior to establishing the HSA eligible for reimbursement?
No. Your HSA is established on the effective date of your Blue Options HSA policy. However, to officially activate your HSA, you must send in your signature card. If you delay, the IRS may infer you intended to open your account at a later date.
Some information about HSAs in this article was sourced from www.ustreas.gov.
Blue Advantage Saver
- What does "generic-only" mean with regards to prescription coverage?
While many of our health insurance plans provide coverage for generic and brand-name prescription drugs, some Blue Advantage Saver plans provide coverage for generic drugs only. Brand-name drugs would involve out-of-pocket costs for the member.
- What is a point-of-service (POS) plan?
A type of HMO health insurance product, like Blue Value, that offers a limited network of providers from which members can select. Members have incentive to use in-network providers to receive richer benefits, but may choose to use out-of-network providers at a higher out-of-pocket cost. Members who choose to use out-of-network providers are responsible for submitting their claims to BCBSNC in accordance with BCBSNC procedures.
- If I visit a doctor or hospital outside the network, am I still covered?
Yes, you may see any doctor you choose. Seeing an out-of-network provider may mean paying more out-of-pocket costs. However, in an emergency, in situations where in-network providers are not reasonably available as determined by BCBSNC's access-to-care standards, or in continuity-of-care situations, out-of-network benefits will be paid at the in-network benefit level.
- Who's eligible for Dental Blue for Individuals?
Applicants and their dependents (spouses or children under the age of 26) who are residents of North Carolina.
- If I cancel my Dental Blue for Individuals coverage, how soon can I reapply?
Reapplying for coverage isn't permitted for 12 months from your policy's termination date.
- Are my monthly premiums subject to change?
You may experience a change in your monthly premiums at the time of your annual renewal (January 1 of each year), or when you add or remove dependents.
- How do I file a dental claim?
Unless your dentist's office files your claim for you, you should pay the dentist in full and submit your claim to BCBSNC for reimbursement. Complete a dental claim form and mail it to us within 180 days from the date of your service.
Mail the completed claim form to:
Blue Cross and Blue Shield of North Carolina
Dental Claims Unit
P.O. Box 2100
Winston-Salem, NC 27102-2100
1 CHP Market Quest, Network Compare, July 2012 (data as of May 9, 2012)
® Mark of the Blue Cross and Blue Shield Association. ®1, SM Mark of Blue Cross and Blue Shield of North Carolina.
2 Blue Options HSA is a high-deductible health plan that may be combined with a health savings account (HSA). BCBSNC does not administer the HSA and is not affiliated with your HSA custodian or administrator.
3 Withdrawals are tax free only if used for qualified medical expenses. Specific regulations and a list of qualified medical expenses can be found in IRS publication 502, available at www.irs.gov.
If you have questions, we've got answers.
Give us a call at 1-800-324-4973.
Hearing and speech impaired (TDD/TTY), please call 1-800-922-3140.
Licensed agents are available to assist you Monday - Thursday, 8 a.m. - 6 p.m. and Friday, 8 a.m. - 5 p.m.
Please do not send membership, claims, billing or benefit inquiries by email. For questions about your plan, please call the phone number on the back of your Member ID card.