Tips for Finding the Right Private Health Insurance – Wisconsin

  • April 26, 2016
  • |Quartz
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A Quick Primer on Private Health Insurance Terms in Wisconsin

Below are private health insurance terms that you need to know before purchasing your own plan.


Common definition

Important details


The monthly or quarterly fee you pay for private health insurance.

Usually, the lower the premium, the more you will have to pay if you actually go to the doctor or need prescriptions.

Out-of-pocket costs

Costs you pay for covered health care service, prescriptions or medical equipment.

Out-of-pocket costs include what you pay out of your own pocket based on your specific plan. This includes copays, coinsurance, the deductible and some other costs. Out of pocket costs do not include services you get out-of-network and other services and equipment that are not covered by your policy.

Provider Network
(in-network vs. out-of-network)

The group of health care providers that have contracts with the insurance company to provide health care services to members at a specific quality and cost level.

It’s important to use the health care providers that are “in-network”, meaning they have contracts with your health insurance company. If you use a health care provider (doctor, therapist, specialists, hospital, clinic, lab, etc.,) that is out-of-network, you may be liable for some or all of the cost, even though you have private health insurance. Further, out-of-network costs may not count towards your deductible or your out-of-pocket maximum for the year.


A predetermined amount of money a member or family must pay per benefit period before your private health insurance will make a payment toward a covered service.

Copayments may or may not count towards the deductible. Out-of-network costs may not count towards the deductible. Certain services and medical equipment do not count toward the deductible. Check any policy very carefully to see what does and does not count toward the deductible.


A set fee you pay for receiving covered health care services, prescriptions or equipment.

You usually pay the copay amount at the time of service; copays may or may not add up toward your deductible. Also, copays for prescriptions and copays for health care services may have separate deductibles.


The percentage of the cost of a covered health care service that you pay.

Insurance companies have contracts with each network provider where they pay specific amounts for each type of service. The coinsurance amount is your share of this contracted rate. You pay coinsurance once you have met your deductible, up to your out-of-pocket maximum. Out-of-network costs above what you would have paid for an in-network service may not add up toward your deductible.

Out-of-pocket Maximum(MOOP)

The maximum amount that you are liable to pay in a policy year for covered services. All private health insurance in Wisconsin is required by law to have a MOOP to prevent excessive medical bills in the case of serious illness or injury.

This amount may or may not be the same as your deductible. The amount includes the costs you pay for covered services only. It does not include any costs you pay for services, prescriptions or equipment that are not covered. For example, if Lasik surgery is not covered by your policy and you get it, the cost of the surgery will not add up toward either your deductible or your out-of-pocket maximum.


If you meet the income requirements, you may be eligible to receive help paying for your premiums and other costs.

Two kinds ofsubsidiesare available because of the Affordable Care Act – Advanced Premium Tax Credits and Cost Share Reductions. If you’re a single person earning between $11,880 and $47,520 per year, you may be eligible.Find out if you qualify.

See If You Qualify and Get a Quote


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