Member Responsibility – Cost Sharing
General
Policy Number: GP-X-059
Last Updated: June 17, 2022
Blue Cross and Blue Shield of Nebraska (BCBSNE) members are responsible for paying a portion of the cost of covered services. The member's cost-sharing responsibility includes applicable deductible, coinsurance and copayments. In limited circumstances, the member also may be responsible for the balance of the provider's charges not reimbursed by BCBSNE. Cost sharing amounts vary by benefit plan.
* Please note: If the information in this section differs from the member’s actual benefit plan, the terms of the member’s coverage will apply.
Allowable Charge
The amount we use to calculate our payment for covered services. For an in-network provider, the allowable charge is based on the lesser of the contracted amount or the billed amount; for out-of-network providers the allowable charge is the lesser of the out-of-network allowance or the billed amount.
Balance bill
"Balance bill" refers to the dollar difference between a provider's billed charges and the BCBSNE allowed amount. Under the terms of their contract with us, in-network providers must accept the allowed amount as payment in full for covered services and may not balance bill the member for the remainder.
STATE: Effective Jan. 1, 2021, providers in Nebraska may no longer balance bill BCBSNE covered individuals for medical care received from out-of-network providers or facilities in emergency situations. The Nebraska Out-of-Network Emergency Medical Care Act (LB997) protects consumers from getting surprise bills from out-of-network providers or facilities for emergency medical services. Facilities are defined as a general acute hospital, satellite emergency department or ambulatory surgical center licensed pursuant to the Health Care Facility Licensure Act. This state mandate applies to all individual policies, fully insured group health plans and non-Employee Retirement Income Security Act (ERISA) self-funded groups.
FEDERAL: Effective Jan. 1, 2022, providers in Nebraska may no longer balance bill BCBSNE covered individuals (pursuant to their plan year start date) for medical care received from out-of-network providers or facilities in emergency situations (to include emergency and related post-stabilization services), nonemergency services provided by a nonparticipating provider in a participating facility, and air ambulance services. The No Surprises Act protects consumers from getting surprise bills from out-of-network providers or facilities for these services. This federal mandate applies to all individual policies, fully insured group health plans and both ERISA and non-ERISA self-funded groups where the state law does not apply.
Deductible
The amount the member must pay for covered services each calendar or plan year before the benefit plan begins to pay for covered services. The deductible applies to all covered services, unless otherwise specified by the member’s plan.
| Calculation of deductible | The deductible is calculated based on the BCBSNE allowed amount for covered services or the billed charge, whichever is less. |
| Application of deductible | A contracted provider must file all claims for members, including those that may require payment of deductibles. Application of the deductible is determined in the order in which claims are processed by BCBSNE, not the date services were provided within the calendar or plan year. |
| What does not apply to the deductible | Member copay amounts do not apply toward satisfaction of the deductible in standard traditional benefit plans. |
| Deductible limits | A deductible can be either embedded or aggregate. In general, traditional plans feature embedded family deductibles. Most qualified high deductible health plans (QHDHP) have aggregate family deductibles. This will vary based on the plan. |
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The entire family deductible must be met prior to any benefits becoming available. One member on the plan may satisfy the entire family deductible, or family members may combine their covered expenses to satisfy the required family deductible. |
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Family members may combine their covered expenses to satisfy the required calendar year family deductible. No one family member contributes more than the individual deductible amount to satisfy the family’s deductible. |
| Deductible carry over | Any amounts applied to the annual deductible for services provided in October, November or December will be carried over and applied to the next calendar or plan year's deductible. Applicable based on the member’s plan. |
Coinsurance
The percentage of covered charges the member pays once the deductible has been satisfied.
Coinsurance applies to every covered service unless the member’s benefit plan states otherwise. Typically, coinsurance percentages differ for in-network and out-of-network providers.
| Calculation of coinsurance | Coinsurance is calculated based on the contracted amount or the billed amount, whichever is less. Members pay more in coinsurance when they use out-of-network providers. |
| What does not apply to the coinsurance limit | Deductible and copay amounts do not apply toward satisfaction of the member’s coinsurance limit. |
| Coinsurance limits | The amount the member must pay each calendar or plan year in coinsurance before BCBSNE begins paying 100% of the allowed amount for most covered services. The member is still responsible for paying applicable copay amounts. |
| Family coinsurance limit | In general, traditional plans feature embedded family coinsurance limits. Most QHDHPs have an aggregate family coinsurance limit. This will vary based on the plan. |
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The entire family coinsurance limit must be met before covered services are paid at 100%. Family members may combine their covered expenses to satisfy the required coinsurance limit. |
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This means that while family members may combine their covered expenses to satisfy the required family out-of-pocket limit, no one member contributes more than the individual out-of-pocket limit to satisfy the family amount. |
Copayments
Copayments are fixed dollar amounts a member must pay to the provider for specific covered services.
If a copay applies, the member must pay it at the time of service.
| Copay amounts greater than BCBSNE allowed amount | The provider may only collect the allowed amount. If the provider knows the allowed amount at the time of service, that amount may be collected at time of service instead of the copay. If the provider later determines that the allowed amount is less than the copay, the difference must be refunded to the member. |
| Copays related to deductible | Even after the member’s deductible and/or coinsurance limit have been reached (except for QHDHPs). |
| Copays related to out-of-pocket limit | Once the out-of-pocket limit has been met – copays no longer apply |
| Common services covered under a copay | Office visits/office services, urgent care facility visits and emergency room visits. Under some plans, copays apply to allergy injections and serum, ambulance services, inpatient admissions and preventive services (those not required to be paid at 100% by the Affordable Care Act). |
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Typically, includes office visits, the initial visit to diagnose pregnancy, consultations, medication checks and psychological therapy and/or substance dependence and abuse counseling/rehabilitation. |
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Typically, includes x-rays, laboratory and pathology services performed in the physician’s office, supplies used to treat the patient in the office, drugs administered by the physician in the office, hearing and vision examinations due to illness, (excluding vision refractions) and allergy testing. |
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Typically, ER copays are waived if admitted to the hospital within 24 hours of the same diagnosis. |
Note: Verify member benefits to confirm what services are subject to copays under the patient’s plan, and how covered services are reimbursed after payment of the copay.
* Please note: If the information in this section differs from the member’s actual benefit plan, the terms of the member’s coverage will apply.
Out-of-Pocket Limit
The maximum amount the member must pay in a calendar or plan year before all services are paid at 100% of the allowable charge. All amounts applied to deductible, coinsurance and copays are applied to the out-of-pocket limit. Once the out-of-pocket limit is met, copays no longer apply.
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