Understanding What Your Health Insurance Covers: Blue Cross or Blue Shield

It is essential to know what your health insurance covers, particularly concerning Blue Cross and Blue Shield policies. However, the extent of coverage depends on the specific policy you have, as both names often represent one company in many locations, though different states may offer varying plans.

Policy Specifics and Verification

For accurate information on what your health insurance covers, you should not rely on online forums. Instead, refer to your member handbook or contact the back of your insurance card for details on the member service number. Request an eligibility and benefits review to understand your coverage thoroughly.

The primary source of information for your coverage is your insurance company's description of coverage document. This document is more reliable than general information available online because it is tailored to your specific policy. If you are unsure or prefer not to read the document, calling the customer service number and inquiring about a specific procedure's coverage can provide clarity.

The Role of Blue Cross and Blue Shield

BlueCross and BlueShield, in most locations, are one company with different policies in each state. This variation means that their offerings are not necessarily the same as in neighboring states. Insurance companies also offer a wide range of policies that provide varying levels of coverage at different rates.

Medicare and Secondary Insurance

If you have Medicare, you might consider Blue Cross or Blue Shield as your secondary health insurance. In such cases, you may observe that Blue Cross/Blue Shield refers to services deemed by Medicare as being worth a certain amount. For instance, BC/BS might state, 'Medicare deems this medical service to be worth X, so BC/BS's share of this amount is X.' Often, this share is significantly lower than the actual value, which can be beneficial for the insurance company.

When I was enrolled in Medicare and had BC/BS as secondary insurance, the cost-sharing arrangements were different. BC/BS's share was frequently under 10%, leading to substantial savings for them. This became particularly evident when I joined a large group with high medical costs, where my out-of-pocket expenses were minimized due to BC/BS's favorable arrangement.

It was not surprising to learn that BC/BS and other insurance companies played a significant role in shaping Medicare rules. Some reports suggest that lobbyists and management of such companies had a substantial influence in the development of the program, leading to arrangements that favored the insurance industry.

Conclusion

Understanding your health insurance coverage, especially when dealing with Blue Cross or Blue Shield, is crucial. Contact your insurance company directly to obtain detailed information and ensure that you are making informed decisions about your healthcare. Remember that the specifics of your coverage can vary significantly based on your policy and location.