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Definitions and Terms
- Coinsurance
- Coinsurance is the percentage of covered charges that you must pay for certain covered services after the deductible has been met. With most plans, after you have met the deductible you will pay a percentage of covered charges for services from a Preferred Provider and a percentage of covered charges for services from a Nonpreferred Provider. Check your Summary of Benefits for the specific percentage of covered charges you will have to pay for different services.
- Copayment
- A copayment is a fixed dollar amount you pay for a service at the time you receive care.
- Deductible
- A deductible is the amount of covered charges you must pay each calendar year before BCBSNM begins to pay its share of the applicable covered charges you incur during the rest of the same calendar year. If you have a PPO plan, there is a separate higher deductible for using Nonpreferred Providers (out-of-network providers).
- Out-of-pocket limit
- An out-of-pocket limit is the maximum amount of coinsurance that you will pay for covered services in a calendar year. After the out-of-pocket limit is reached, your plan will pay 100 percent of most of your Preferred Provider or Nonpreferred Provider covered charges for the rest of that calendar year, not to exceed any benefit limits.
