St Joseph Medical Center

An in-network provider agrees to accept your plan's allowed amount. The difference between its charge and that amount is written off: you don't owe it, and it shouldn't appear on your bill.

What you pay each year before your plan starts sharing costs. It is applied to bills in the order your plan processes them, so the first bill can take all of it.

A fixed amount for a kind of care, such as a hospital stay or a surgeon's visit. Your plan's summary of benefits says whether it applies before or after the deductible, and whether a stay's copay is per day.

Your percentage of the allowed amount after the deductible, such as 20%.

Once your deductible, copays and coinsurance for the year reach it, your plan pays 100% of covered in-network care for the rest of the plan year.

The hospital, surgeon, anesthesia group, radiologist and pathologist each send their own claim and their own bill. All of them count toward the same deductible and yearly maximum.

A provider outside your plan's network can bill you the difference between its charge and what your plan pays (a balance bill). It can't for emergency care, or when anesthesia, radiology, pathology, an assistant surgeon or a hospital doctor treats you at an in-network hospital: under federal law (the No Surprises Act) and, for Washington-regulated plans and self-funded plans that opt in, RCW 48.49, those groups cannot balance bill you. Your deductible and coinsurance still apply, at in-network amounts.

If your plan decides a service isn't covered, or it needed prior authorization that wasn't approved, the plan pays nothing for it and the provider may bill you. Ask the provider to get prior authorization before your care. If an in-network provider didn't get it, the provider's contract may stop it billing you: ask your plan before you pay.

If you have a second plan, the first plan pays first and the second may then pay some or all of your share. These estimates use one plan only.

After each claim your insurer sends an Explanation of Benefits (EOB) with the allowed amount, what it paid and what you may owe. It is not a bill. Pay a provider's bill only when it matches the EOB's “you may owe” amount, and ask the provider or insurer about any difference.

Washington hospitals must give free or discounted care based on income, including deductibles and coinsurance for insured patients: free up to 200% or 300% of the federal poverty level depending on the hospital, with discounts above that (RCW 70.170). You can apply after you get a bill. It covers the hospital's bill; doctor groups that bill separately have their own policies.

You can choose not to use your insurance and pay the cash price; then nothing counts toward your deductible. Ask each provider for a Good Faith Estimate. If a bill is $400 or more above it, you can dispute it within 120 days.