Paying for Covered Services

What do you pay for covered services?

Copayments and coinsurance are the amounts you pay for covered services.

  • A "copayment" is a payment you make for your share of the cost of certain covered services you get. A copayment is a set amount per service. You pay it when you get the service.
  • "Coinsurance" is a payment you make for your share of the cost of certain covered services you receive. Coinsurance is a percentage of the cost of the service. You pay your coinsurance when you get the service.

Medical Explanation of Benefits (EOB)

You will receive a medical Explanation of Benefits (EOB) from Blue Cross and Blue Shield of Louisiana, and its subsidiary, HMO Louisiana, Inc. once a month regarding your processed medical claims. This is not a bill. Your Explanation of Benefits (EOB) will provide clear information on what care you have received, what we have paid, how much you have paid out-of-pocket (or can expect to be billed), and your appeal rights. If you owe anything, your doctors and other health care providers will send you a bill.

What is the maximum amount you will pay for covered medical services?

There is a limit to how much you have to pay out of your own pocket for covered healthcare medical services each year. Please see the chart below for maximum out-of-pocket limits for services provided in-network for the benefit year.

 

Plan Max Out-of-Pocket Limit
Blue Advantage (HMO) Northwest (005) $6,700
Blue Advantage (HMO) Northeast (006) $6,700
Blue Advantage (HMO)
Ascension, East Baton Rouge (007)
$4,900
Blue Advantage (HMO)
East Feliciana, Iberville, Livingston, Pointe Coupee,
St. Helena, West Baton Rouge, West Feliciana (007)
$6,700
Blue Advantage (HMO)
Jefferson, Lafourche, Orleans, St. Charles,
Terrabonne (008)
$4,900
Blue Advantage (HMO)
Assumption, Plaquemines, St. Bernard, St. James,
St. John the Baptist (008)
$5,500
Blue Advantage (HMO)
St. Tammany, Tangipahoa (009)
$3,900
Blue Advantage (HMO)
Washington (009)
$4,500
Blue Advantage (HMO)
Acadia, Calcasieu, Iberia, Lafayette,
Rapides, St. Landry, St. Martin, Vermilion (010)
$4,900
Blue Advantage (HMO)
Allen, Avoyelles, Beauregard, Cameron, Evangeline
Grant, Jefferson Davis, St. Mary, Vernon (010)
$5,200
Blue Advantage (PPO) Baton Rouge (001) $3,500 (In-Network)
$7,000 (Combined In- and Out-of-Network)
Blue Advantage (PPO) Greater New Orleans (002) $3,500 (In-Network)
$7,000 (Combined In- and Out-of-Network)
Blue Advantage (PPO) North Shore (003) $3,700 (In-Network)
$7,400 (Combined In- and Out-of-Network)
Blue Advantage (PPO) Acadiana (004) $3,500 (In-Network)
$7,000 (Combined In- and Out-of-Network)
Blue Advantage (PPO) Northwest (005) $3,700 (In-Network)
$7,400 (Combined In- and Out-of-Network)
Blue Advantage (PPO) Northeast (006) $3,700 (In-Network)
$7,400 (Combined In- and Out-of-Network)

Services that apply to the maximum out-of-pocket are noted in the benefits chart in the Evidence of Coverage.

Benefits Chart

The benefits chart located in the Evidence of Coverage lists the services our plan covers and what you pay for each service. The covered services listed in the Benefits Chart are covered only when all requirements listed below are met:

  • Services must be provided according to the Medicare coverage guidelines established by the Medicare Program.
  • The medical care, services, supplies and equipment that are listed as covered services must be medically necessary. Certain preventive care and screening tests are also covered.
  • Some of the covered services listed in the Benefits Chart are covered only if your doctor or other in-network provider gets "prior authorization" (approval in advance) from our plan.

Blue Advantage

To be a member of Blue Advantage you must continue to pay your Medicare Part B premium.

You must pay the full cost of services that are not covered.

You are personally responsible to pay for care and services that are not covered by Blue Advantage. If you are a Blue Advantage (PPO) plan member, you may pay more for services obtained out-of-network. If you are a Blue Advantage (HMO) plan member, you must pay for services you receive from providers who are not part of the Blue Advantage network unless HMO Louisiana, Inc. has approved these services in advance. The exceptions are care for a medical emergency, urgently needed care, out-of-area renal (kidney) dialysis services, and services that are found upon appeal to be services that we should have paid or covered.

For covered services that have a benefit limitation, you must pay the full cost of any services you get after you have used up your benefit for that type of covered service. You can call Customer Service when you want to know how much of your benefit limit you have already used.

Please keep us up-to-date on any other health insurance coverage you have.

If you have other health insurance coverage besides Blue Advantage it is important to use this other coverage in combination with your coverage as a member to pay for the care you receive. This is called "coordination of benefits" because it involves coordinating all of the health benefits that are available to you. Using all of the coverage you have helps keep the cost of healthcare more affordable for everyone.

You must tell us if you have any other health insurance coverage besides Blue Advantage, and let us know whenever there are any changes in your additional insurance coverage.

How do I pay my monthly premium and/or Late Enrollment Penalty (LEP)?

For questions about your monthly premium and/or Late Enrollment Penalty, please contact your employer group.

  • If you choose the direct bill method, you will receive an invoice on or about the 10th of the month. Payment of that invoice is due on the first day of the month for that month’s coverage. You will then have the option to pay your premium with a check or you can pay by credit card using the instructions included in the invoice.
  • If you choose the SSA or RRB premium withhold method, the Social Security Administration will withhold the premium from your SSA/RRB check on a monthly basis.
  • If you choose to pay by electronic funds transfer, your premium will be transferred from your bank account on or about the 9th of the month for coverage that month.

It can take several months for premiums to start being deducted from SSA benefits. Do not send a payment check during this time. When the withholding begins, you’ll see a deduction for the months during which you had coverage but the premium wasn’t withheld from your check.

If you are switching plans, premiums from your old plan may still be deducted from your SSA benefits. As soon as the systems are updated, if the difference in your 2019 premium is less than your 2018 premium, SSA will refund the difference. If the difference in your 2019 premium is greater than your 2018 premium, the difference will be deducted from your SSA payment.

If you have any questions about your plan premiums or the payment programs, please call Customer Service.

Y0132_19-529_ITLU - Last updated 01/30/2020