Consider what health care you know you will need, and the level of unexpected medical expenses you want the plan to pay for instead of paying them yourself. There are many options to choose from.
The Health Tradition network includes all Mayo Clinic Health System locations in western Wisconsin and additional community hospitals, clinics and other providers.
Our formulary is a list of prescription drugs chosen for their proven effectiveness, safety and best cost. We update the formulary throughout the year to take advantage of the latest Mayo Clinic research and manage costs.
Reaching age 26
New baby or adoption
Moving or moved
Job change or loss of coverage
We’ll calculate your premium and let you know if you qualify for reduced cost.
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
When a provider bills you for the difference between the provider’s charge and the amount your plan covers.
A category of health plan in the Marketplace. A Bronze plan will pay about 60% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. While coverage is less than Gold or Silver, the premium is also less. A Bronze plan may be a good choice if you expect almost no doctor visits and require no regular prescriptions. An unexpected accident or illness can cancel out the savings.
Covers essential health benefits but is primarily “safety net” coverage for a serious accident or illness. Premiums may be lower than traditional plans but deductibles are higher. In the Marketplace, these plans are available only to people under 30 and to some with low incomes. People with catastrophic plans are not eligible for cost support.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service.
Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. The deductible may not apply to all services.
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Health care services that your health insurance or plan doesn’t pay for or cover.
Also referred to as a Section 125 account or cafeteria plan. An FSA allows you to pay for qualified medical expenses with pre-tax dollars. Dollars do not carry over at the end of the year, so planning is required.
A list of drugs specifically chosen to be covered by a prescription drug plan. Drugs with well-proven effectiveness and reasonable cost are likely to be on this preferred list.
A drug that has the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand name drugs.
A category of health plan in the Marketplace. A Gold plan will pay about 80% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. Coverage is greater than Silver or Bronze plans, but premiums are higher. Do you expect a lot of doctor visits or need a lot of prescriptions? A Gold plan may be a good choice. Gold gives you more protection from an accident or unexpected illness than Silver or Bronze.
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Also called the “exchange,” and “HealthCare.gov,” the Marketplace is an internet-based system run by federal and some state governments. It standardizes health plans from different companies so they can be compared more easily and purchased by consumers. The system will show you plans available in your area based on your answers to some questions. The Marketplace will also tell you if you qualify for free or low-cost coverage through Medicaid or other programs.
Plans that reimburse employees for incurred medical expenses not covered by the company’s insurance plan. The employer funds the HRA. Reimbursement dollars received by the employee are generally tax-free. The employer decides if any unused funds can be rolled over for use the following year.
An account created for individuals covered under high-deductible health plans (HDHPs) to save for medical expenses the plan does not cover. Account is funded by the individual or an employer and is used to pay for qualified medical expenses such as dental, vision and over-the-counter drugs.
HDHP plans typically have lower premiums and higher deductibles than other plans. HDHPs are used with health savings accounts or health reimbursement accounts to pay for qualified out-of-pocket medical costs. The accounts are funded with pre-tax dollars, lowering the amount of federal taxes you owe.
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Care in a hospital that usually doesn’t require an overnight stay.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
The percent you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network coinsurance.
A fixed amount you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network co-payments.
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A provider who doesn’t have a contract with your health plan to provide services to you. You’ll pay more to see a non-preferred provider.
The percent you pay of the allowed amount for covered health care services to providers who do not contract with your health plan. Out-of-network coinsurance usually costs you more than in-network co-insurance.
A fixed amount you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or care your health plan doesn’t cover.
Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
A category of health plan in the Marketplace. A Platinum plan will pay about 90% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. Coverage is greater than Gold, Silver or Bronze plans, but premiums are higher. Do you expect a lot of doctor visits, have a chronic condition or need a lot of prescriptions? A Platinum plan may be a good choice. Platinum gives you the most protection of all plan categories.
These plans let you choose where to get care but if you use out-of-network providers and facilities, you’ll have to pay more than you will in-network.
A decision by your health plan that a health care service is medically necessary. Sometimes called prior authorization. Your plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health plan will cover the cost.
A provider who has a contract with your health insurer or plan to provide services to you at a discount.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Drugs and medications that by law require a prescription.
Screenings or exams to diagnose illness in its earliest stages. Certain preventive care is covered by health plans at no charge.
A physician, nurse practitioner, clinical nurse specialist or physician assistant who provides, coordinates or helps a patient access health care services.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
A physician, health care professional or health care facility licensed, certified or accredited as required by state law.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Services that help a person regain skills and functioning for daily living that have been impaired by illness or injury. Services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation, in inpatient or outpatient settings.
A category of health plan in the Marketplace. A Silver plan will pay about 70% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. Coverage is greater than Bronze plans, but premiums are higher, though not as high as Gold plans. A Silver plan may be a good choice if you expect fewer doctor visits and require no regular prescriptions. An unexpected accident or illness can cancel out the savings.
Services from licensed nurses, technicians and therapists in your own home or in a nursing home.
The amount paid for a medical service based on what providers in the area usually charge for the same or similar medical service.
Care for an illness, injury or condition serious enough to seek care right away, but not requiring emergency room care.