If you’ve been shopping for individual healthcare plans, you’ve probably noticed big differences between premiums and other costs, such as deductibles and copayments. How do you know what you actually will be paying for a specific service? Several factors determine what you'll be required to pay out-of-pocket, including –
Metal Level – Individual healthcare plans are broken down into 5 metal levels depending on how much coverage they provide: bronze, silver, gold, platinum and catastrophic. The more coverage provided, the less you'll pay out-of-pocket for health care services
Deductible – The higher the deductible, the more you'll be required to pay out-of-pocket before your health plan coverage kicks in
Plan Type – The most popular types of health care plans for individuals are HMO, PPO, EPO and POS. Some plan types offer both in-network and out-of-network benefits and some don't. The amount you'll pay out-of-pocket can depend on which type of health plan you have and whether you plan to see an in-network or out-of-network provider
Coinsurance vs. Copays – Coinsurance is a percentage that you are required to pay for a specific service, and the amount you pay depends on how much your provider chargers for that service. A copay is a set amount for a specific service and does not change. Individual healthcare plans can have either coinsurance or copays, or both. This is one major reason out-of-pocket costs vary so much between plans
What will my costs be?
How can you estimate what a visit to the doctor will actually cost? A good place to start is to view the Summary of Benefits and Coverage, which provides the details of an individual health care plan. This document spells out the various out-of-pocket costs, including the deductible, copays, coinsurance and your annual out-of-pocket maximum. It also provides coverage examples to illustrate how much you may pay for certain services. Watch a quick video for help understanding your Summary of Benefits and Coverage document.
If you’re a patient of UW Health, UW Hospitals and Clinics offers the UWHC Priceline phone number, 608.263.1507, to check costs ahead of time. UW Health also offers a number to call if you want to find out what your potential physician charges may be – 608.829.5637. They will provide a CPT code and the total billed estimate. This is the information you need to provide to your insurance company to find out what your individual health care plan will cover.
Out-of-pocket costs can vary greatly between individual healthcare plans. However, there are many resources to help you estimate the costs of different services based on your situation. If you have questions about what a specific services may cost you, call our helpful customer service representatives at 800.362.3310 for accurate and timely information.