The Group Insurance Board made changes to the Uniform Benefits package effective January 1, 2012 for State of Wisconsin employees who are not eligible for Medicare nor enrolled in Medicare as the primary payor. These changes included the implementation of cost sharing (for example, coinsurance) for certain services. Cost sharing can be confusing, so we've compiled some resources to help you better understand your benefits.
Please note: these changes do not affect retired participants for whom Medicare is the primary payor or Local participants.
What is covered under "routine, preventive services"?
Routine, preventive care is care that is designed to help prevent disease, or to diagnose it in the early stages. Under the Affordable Care Act, you may receive access to preventive health care services at no cost to you when delivered by a network provider. Unity covers routine physical exams, routine gynecological exams, routine child health exams and immunizations for covered children up to age 26 without requiring a copayment, coinsurance or deductible. View a list of preventive services covered.
What is coinsurance?
Coinsurance is the term used to identify the percentage of health care costs you are responsible for paying the provider.
Your coinsurance for injury related services is 10%
You visit the doctor for an injury resulting in a bill of $500
You must pay 10% of this bill ($50) and the insurance company will pay the remaining 90%
What is an Explanation of Benefits (EOB)?
If you are responsible for out-of-pocket expenses such as a copayment, coinsurance, deductibles or amounts in excess of a usual, customary and reasonable charge, Unity will send you an Explanation of Benefits (EOB). (See a sample Unity EOB.) Learn more about EOBs or sign-up in MyChart to receive them electronically.
What is an annual out-of-pocket limit (OOPL)?
This is the total dollar amount that you are responsible for paying for health services or health costs including deductibles, copayments and coinsurance. Please note: payment for some services may be excluded from your OOPL; refer to your Schedule of Benefits or Summary of Benefits and Coverage for details.
Your OOPL is $500 per individual/ $1,000 per family
Your coinsurance for illness and injury related services is 10%
Your Emergency Room copay is $75 (does not accumulate to OOPL)
Family Out-of-Pocket Total
Visit 1- You have an injury
Visit 2- Your spouse has an illness
Visit 3- You visit the Emergency Room
$75 copay (does not count towards OOPL) $117.50 coinsurance (10% coinsurance on balance after copay)
Visit 4- You receive preventive care
Visit 5- You have an injury
$232.50 coinsurance** (remaining $267.50 would exceed your OOPL)
*Spouse's OOPL has been satisfied ($500 OOPL per individual). Unity pays 100% of covered services for the remainder of the Benefit Year for your spouse (with the exception of services excluded from OOPL).
**Your family out of pocket limit has been satisfied. Unity pays 100% of covered services for the remainder of the Benefit Year for you and all other family members (with the exception of services excluded from OOPL).
The amounts listed above are example amounts only. To get a better idea of what your out-of-pocket costs might be, refer to: