How you and insurance pay for your healthcare

Healthcare costs include the deductible, coinsurance, copayment and out-of-pocket maximum. Learn more about these healthcare costs and how to pay for them.

How to pay for your healthcare

It isn’t always easy to understand how and who to pay for your healthcare. Here’s a simple example:

 

Image of how to pay for your health care. 1 Go to your doctor; 2 Your provider sends a claim to Blue Cross; 3 Blue Cross determines the allowed cost of the visit; 4 Blue Cross pays what it owes to your provider and send you an explanation of benefits; 5 your provider sends you a bill; 6 check that your explanation of benefits and bill match; 7 pay your provider
  1. Visit a doctor that is in your plan network* and present your member ID card. If your plan has copays, you pay the copay at the time of service.
  2. Your doctor files a claim to Blue Cross with the details about your visit.
  3. Blue Cross reviews the claim and determines the allowed amount (cost) of the service. The allowed amount is a cost agreed to between Blue Cross and the doctor.
  4. Blue Cross will send a summary to your doctor explaining how much the health plan and the member will pay on the claim. Blue Cross also sends you an Explanation of Benefits (EOB) with the same information.
  5. Once your doctor has received the claim and any payment due from Blue Cross, your provider will send you a bill for the amount you owe as part of your deductible or coinsurance. 
  6. Compare the EOB from Blue Cross with the bill from your doctor and be sure it matches.
  7. Send your payment directly to your doctor.

Note: If your health plan owes money for services you received from a doctor outside your plan network, Blue Cross sends a check to you for that amount. You must then pay the doctor for the full amount of the bill.

What costs will I pay for in-network healthcare?

You'll pay a monthly premium for your health plan, plus costs for some medical services. You pay the premium directly to your health plan or your employer deducts it from your paycheck.

Other costs you may pay include:

  • Deductible: the amount you pay for care each year before your plan begins to pay
  • Coinsurance: a percent of the cost you may pay for some services
  • Copayment: a small, flat fee you may pay for some services
  • Out-of-pocket maximum: the most you will pay for covered services each year

Do I pay Blue Cross for my healthcare?

No. When you visit a doctor, hospital or pharmacy, you pay the amount you owe directly to that provider.

More about healthcare costs

How do I track and see my claims?
When does a preventive visit turn into an office visit?
How to read an Explanation of Benefits (EOB)
7 ways to save on health care
What is prior authorization?

This is general information about how plan benefits work. Review the Summary of Benefits and Coverage and your specific health plan benefit booklet for information about how your plan works.

It’s up to you to always check if your provider is in your health plan network before you receive services. Not all providers are in every network. You may pay more or for all of your healthcare costs if your provider is out of your network or does not have a contract with Blue Cross (this is called a non-participating provider). You can verify if your provider is in your network by calling customer service at the number on the back of your member ID card.