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understanding healthcare coverage.

Private healthcare coverage can be complicated. Use this guide to learn

  • What it is
  • How it works
  • Why you need it
  • How Blue Shield can help you get covered

What is it?

Healthcare coverage is a way to help you pay for medical care while providing you access to a network of doctors and hospitals.

How does it work?

First, you buy a health plan. A health plan determines the types of medical services you are covered for and how much you will pay when you get care.

When you need medical care, you visit a doctor or hospital in your plan's provider network. This is a group of doctors and hospitals that have agreed with the health insurance company to charge certain amounts for each service. Your costs for care are usually lower when using network providers. Having health coverage can save you money each time you get care.

Healthcare coverage isn't just for when you're sick. Preventive care services can help keep you and your family healthy by monitoring your health and catching problems early when they may be more easily treated.

What do I
pay monthly?

Each month, you pay a premium for your health plan. The amount depends on the plan you buy. The lower your plan's premium, the more you typically pay when you see the doctor and vice versa. Understanding how often you see a doctor can help you choose the right plan for you.

What do I
pay for care?

It depends on the service. Some services have a copayment, which is a fixed dollar amount. Other services have a coinsurance, which is a fixed percentage amount. When you get care from a network doctor, you pay the copayment or coinsurance and the health plan pays the rest up to the allowable amount.*

Some health plans have an annual deductible, which is the amount of money you pay for services before the coinsurance and health plan begin paying for them.

To protect you and your family from unexpected costs, most plans have an annual out-of-pocket maximum. Once you reach the out-of-pocket maximum, your health plan covers 100% up to the allowable amount for most covered medical services.

To learn more, watch our helpful videos on how our HMO and PPO health plans work.

*Although some plans let you get care from hospitals and doctors who aren't in the plan's network, you'll pay more to see those non-network providers. The plan may also have other costs, such as a separate, higher deductible, for seeing these providers. These extra costs can be very high, so it's smart to get care from network providers.


  • Allowable amount – The total dollar amount your health plan will pay for your medical services.
  • Affordable Care Act – The act that President Obama signed into law on March 23, 2010, to increase the quality and affordability of health insurance, lower the costs of healthcare for people, and get more people insured. The act includes financial assistance to encourage enrollment in a health plan.
  • Benefits (covered services) – The medically necessary services and supplies that your health plan covers.
  • Coinsurance – The percentage amount a member pays for benefits after meeting any calendar-year deductible.
  • Copayment – The fixed dollar amount a member pays for benefits after meeting any calendar-year deductible.
  • Covered California – The health exchange, run by the state of California, where Californians can purchase health plans and receive assistance to pay for coverage.
  • Deductible – The amount a member pays each calendar year for most benefits before Blue Shield begins to pay. Some benefits, such as preventive care, are covered before the member meets the calendar-year deductible.
  • HMO – A kind of health plan that charges members a monthly premium in exchange for access to care from a network of local doctors, hospitals and other providers.
  • Network – A group of providers, including hospitals, doctors, specialists and other healthcare providers who have agreed with Blue Shield to provide benefits to members of a health plan.
  • PPO – A kind of health plan that charges members for the choice of getting care from a network of doctors and hospitals for set costs or from non-network providers that may charge more than network providers.
  • Providers – Any health care or mental health professional or facility, such as doctors, specialists, hospitals, urgent care centers, laboratories and pharmacies.

Learn more about our health plans

Everyone's different. That's why we offer a wide range of health plan options. Learn more about the plans that are available to you.

Get a quote

Open enrollment ended January 31. You must have experienced a life event to apply for coverage at this time.

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Call for assistance. Toll-free (888) 626-6780. TTY 711.