Understanding Health Insurance

Most health insurance plans have three different stages that determine how much you and your health care company pay for health care services.

1. Before you meet your deductible: Each plan year begins with a new deductible, which is the dollar amount you pay for services and/or medications before your plan begins to pay any costs. You pay out of pocket until you’ve paid your deductible in full. Once you’ve paid your deductible, your health plan will begin to pay for its share of covered services. Remember that your health plan includes certain services at no cost to you before you meet your deductible. These zero-cost services are defined by the Affordable Care Act’s preventive services provision. Learn more about our zero-cost benefits.
2. After you meet your deductible: Once you have paid your deductible, you only pay for a portion of your medical services. During this stage, you pay a percentage (co-insurance) of certain medical services and/or a fixed fee (co-payment) for others. Your health plan pays for the remaining balances after your co-insurance or co-payment. You’ll continue to pay co-insurance and/or co-payments until you reach your out-of-pocket maximum for the year.
3. When you reach your out-of-pocket maximum: Your out-of-pocket maximum is a limit on the amount you will pay for covered services (medical or prescriptions) in a calendar year. It is the most you will be asked to pay from your own pocket during a plan year for covered services. After you meet the out-of-pocket limit, your health plan pays 100% of all covered services with in-network providers for the remainder of the calendar year.

Know Before You Go

You have a variety of options when it comes to receiving care. Understanding those options, keeping yourself well after a procedure or treatment, and determining how to make the right care choice for your situation may save you time and money. Use our form to save time and make the most out of your next provider visit.

Know Before You Go Tips

As costs, prior approval requirements, and plan benefits will vary depending on your health plan, we encourage you to log in to the Member Resource Center to check your plan-specific benefits as you prepare for your upcoming health services.

In most non-emergency cases, call your provider's office when you need care—even after-office hours.

Care options when it's not an emergency

Primary Care Provider

For most urgent care and common health issues during office hours, call your provider's office, unless you think you have an emergency. Sometimes your provider, or a provider who is covering, may be available to help 24 hours a day, seven days a week (check with your provider about extended service hours). Also, be sure to ask your provider if you should call about care for an urgent condition when the office is closed.

Telemedicine

Visit with a provider virtually via your computer, phone, or tablet. Telemedicine providers are available 24/7. The connection is live and protects your privacy. We have a partnership with American Well (Amwell)*, a nationally acclaimed telemedicine vendor. Learn more about our telemedicine services.

Care options when you need immediate attention

Urgent Care

Urgent Care provides services for when you have a condition, illness, or pain that is not an emergency but could cause harm if not treated within 24 hours. Consider Urgent Care services if your Primary Care Provider’s office is closed but you do not think you have an emergency. You can go to Urgent Care for injuries such as minor cuts that may need stitches, minor back pain, and sprains/strains.

Emergency Room

An Emergency Medical Condition is any medical condition that has really bad symptoms (including severe pain) and need immediate medical care. This includes pain, illness and injuries that could affect the whole body, any body part or organ. For a pregnant woman, this includes pain, illness or injury that could seriously affect her or her unborn child. For emergency conditions, go to the nearest doctor, emergency room or call 9-1-1. Seek emergency care for severe chest pain, severe trauma or bleeding, and difficulty breathing.
 

Your Blue Cross and Blue Shield of Vermont member ID card includes important information about your plan. You will receive an ID card for you and each covered family member. 

Your ID card helps make sure you get billed the right amount for your care. It also lets in-network providers know where to send your claim, so you don’t have to. It is important to always carry your card(s) with you, especially when you visit a doctor, pharmacy, or other medical provider. Your member ID provides:

• Your name and member identification number (and a group number, if applicable)
• The name of your plan
• Your copay amount when you go to the doctor or emergency room
• Information for your pharmacist about prescriptions
• Instructions for providers or pharmacists for how to submit a claim
• Customer service phone numbers for you and your providers

If you lose your ID card or it becomes damaged, log on to the Member Resource Center to request a replacement card. You can also call the Customer Service team at (800) 247-2583, Monday-Friday, 7:00 a.m. - 6:00 p.m.