Understanding Your Health Insurance
UW Health is committed to providing remarkable care and service to our patients and families. This includes helping you understand what health insurance is and explaining some common health insurance terms. If you have questions about your coverage, we also encourage you to check with your insurance company.
Health Insurance Terms
In-Network refers to select groups of doctors, hospitals and other healthcare professionals who are contracted with your insurance to provide a full range of covered healthcare services.
- To keep costs low when using your plan, you’ll want to make sure you stay “in-network.” If you visit a doctor outside of your network, you may have to pay more for your care. In some cases, you may have to pay the full cost.
- Contact your insurance company to find out which providers are “in-network.” These providers may also be called “preferred providers” or “participating providers.”
Allowed Amount is the amount that your health insurance or plan will pay for a particular service. The allowed amount can be different for in-network versus out-of-network providers and facilities.
A Premium is the amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly. It is not included in your deductible, your copayment, or your co-insurance. If you don’t pay your premium, you could lose your coverage.
A Deductible is the amount you owe for healthcare services your health insurance or plan covers before your health insurance begins to pay.
- For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid the first $1,000 toward your healthcare services.
- The deductible may not apply to all services. You will want to check with your insurance company for any exclusions.
Co-insurance is your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the total cost for the service. You pay co-insurance after you have met your deductible.
- For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20 percent would be $20. Your health insurance pays the rest of the allowed amount.
A Copayment, or copay, is an amount you are required to pay as your share of the cost for a medical service, like a doctor’s visit or prescription
drug. A copay is usually a fixed amount, rather than a percentage.
- For example, you might pay $20 for a doctor’s visit, lab work, or prescription.
- You may have different copayments depending on the type of service. For example, a copayment for a visit to an emergency department may be different than a copayment for a visit with your primary care doctor.
Out-of-pocket maximum is the most you’ll have to pay for covered services in a benefit year. After you reach this amount, your health plan will pay for all covered health benefits from an in-network provider.
- This limit includes deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual for a medical expense
- This limit does not have to include premiums or spending for nonessential/elective health benefits.
What is Health Insurance?
Health insurance is a contract between you and your health insurer to cover your medical expenses. Your health insurance company helps pay for some or all your medical care, depending on the type of insurance plan you have.
What Payments are Required Before or at the Time of Service?
UW Health assists our patients by researching your coverage and benefits directly with insurance companies to better understand what you may owe. We ask that you pay your estimated out-of-pocket liability (copayment, co-insurance, deductible) prior to service. When we ask for an estimated prepayment, it is not the exact amount that you may ultimately owe. Due to the personalized nature of medicine, patient differences, and the potential for unforeseen complications, it is only an estimate.
After your insurance processes the claim, you will either be billed any remaining amount due or refunded any overpayment. Please note if you have any patient balances for other dates of service, your overpayment will be applied to those balances.
What if I Cannot Pay Before or at the Time of Service?
UW Health will not deny access to emergent or urgent care. We will work with you to assure that you receive the care you need when you need it. Our team of financial counselors can work with you to review government program eligibility, set up payment plans, identify other possible
coverage options, and discuss our financial assistance program where applicable. For assistance, please call (877) 565-0505.