Frequently Asked Questions About Insurance Coverage

 

Absolutely. When speaking to your insurance, first determine if your specific plan is in or out of network at Northwestern Medicine. If out of network, you will need a referral from a physician; however, you may still incur large out-of-pocket expenses. To avoid large out-of-pocket expenses, it is recommended that you seek providers that are in network unless a specialty service is only performed at that location.

It is also important to find out what specific services, procedures and tests will be covered before your arrival. Insurance companies may have coverage limits depending on the service or room charges. Lastly, it is helpful to know and understand what your co-payments, deductibles and/or co-insurance amounts are, depending on your type of service.

Northwestern Medicine will contact your insurance at the time of admission, if your insurance requires it, or after each visit. Northwestern Medicine will file insurance claims directly with your primary insurance company.

You may be able to choose an individual plan without a subsidy off the exchange through a health plan such as Aetna, Cigna, Humana, United Healthcare or Land of Lincoln. These plans are available through healthcare.gov*, a broker or directly from the plan. Please contact your broker, health plan or refer to healthcare.gov* for additional information about available options for your health insurance coverage.

A commercial insurance plan is a type of health insurance that covers medical expenses for the insured. Commercial health insurance policies can be sold individually or as part of a group plan, often through an employer.
Tiered provider networks are essentially a variation of a long-standing practice of providing one level of benefits to those who use in-network providers and another level of benefits for use of out-of-network providers. Tiered provider networks allow employers and insurers to specific hospitals and providers in their plan. Different tiers may have varied out-of-pocket expenses for the health plan. Participants will have more of an incentive to become engaged in the process of provider and treatment selection.
Narrow networks are health insurance plans that place limits on the doctors and hospitals available to their subscribers.
Exchange products are commercial health insurance plans made available to individuals and groups as part of the Affordable Care Act.
The benefit plan is a description of the healthcare services and supplies that a health insurance company covers for members of a specific health insurance plan.
This is the specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a "co-pay." For example, your health insurance plan may require a $15 co-payment for an office visit or brand name prescription drug, after which the insurance company often pays the remainder of the charges.
The specific dollar amount your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims in your deductible. Not all health insurance plans require a deductible. As a general rule, HMO plans typically do not require a deductible, while most Indemnity and PPO plans do.
This is a statement sent from the health insurance company to a member listing services that were billed by a healthcare provider, how those charges were processed, and the total amount of patient responsibility for the claim.
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