A new year is upon us and, for some, that means changing health insurance plans or carriers. Navigating the world of health insurance can be very overwhelming, especially if you haven’t really needed to use your benefits. Each insurance company is very different and each plan within a given insurance company is different. This blog is here to give a broad overview to help you decipher some of the common lingo that is thrown around so that you can feel confident in how your health insurance plan is set up.
Let’s start with the basics. Under most health plans, specific services like physical therapy will either be covered based on deductible & coinsurance or require a copay.
Deductible:
The deductible is the amount of money you would have to pay BEFORE your insurance starts paying. For example: if you have $2,000 deductible, you would be responsible for paying $2,000 before your insurance begins covering some (or all) of your health care expenses. A lot of insurance companies will have a certain allowable amount per service that can be billed, which means you will likely receive a write-off of some sort. This means that if an insurance company is billed $300 for a physical therapy appointment, they will adjust this amount by a certain percentage and then you would be responsible for this new amount. This will continue until you meet your deductible. Each insurance plan has a different way of determining the allowable amount, so we won’t know what this amount will be until after a claim has been processed.
So you’ve reached your deductible… Now what? Once you’ve reached your deductible, the insurance company starts pitching in for your medical expenses. Hurray! But you aren’t completely off the hook yet. Your plan will likely have coinsurance that will now kick in since your deductible is met.
Co-insurance:
Co-insurance is based on a percentage. Going back to our example earlier, you’ve reached your $2,000 deductible and your plan says you have a 20% co-insurance. This means that now you will pay 20% of the cost of the appointment, and your insurance company will pick up the remaining 80%. There are many different co-insurances, some as low as 5% and others as high as 50%. It truly just depends on what plan you have. With co-insurance, you are not responsible to pay this percentage upfront because it is based on the total after the insurance company completes their write-off process. At Complete Physical Therapy, we send out statements on the 15th of each month with any balance that you owe.
Copay:
A copay (or copayment) is a dollar amount, which can vary from plan to plan and different service types (primary care, physical therapy, chiropractic, mental health therapy, etc.). If you have a copay for a certain service, you will pay this dollar amount at each visit if you haven’t hit your out of pocket maximum (more on this later). Most of the time, if you have a copay, you will not owe anything else for your session, as the deductible and co-insurance won’t typically apply. Some payments will count towards your deductible and your out of pocket max, other payments will only count towards one or the other. It all depends on your specific plan.
Out of Pocket Max:
I bet you are wanting to know when you can expect the insurance company to pick up 100% of your health care expenses. At some point during the year, if you have a lot of doctor’s appointments or have a baby or break a bone (yikes!), you will hopefully reach your out of pocket maximum or out of pocket max. Once this happens, you are finally off the hook and can expect your insurance to pick up the cost of your health care as long as the services are part of your benefits. The out of pocket max is a dollar amount that is typically higher than the deductible and varies from plan to plan.
Limits:
Your health plan will sometimes put limits on certain services. This may mean that you will only get so many visits per service per year. Health plans will sometimes combine these limits, for example, you may get 60 visits total per year of physical therapy, but it’s also combined with occupational therapy, and speech therapy.
Referrals & Authorizations:
Each plan is different when it comes to needing a doctor referral or prior authorization. It is the patient’s responsibility to get a referral if their plan requires it, but it is the clinic’s responsibility to do prior authorization. A lot of the time, these two things are not required for physical therapy, but each company and plan are different. Feel free to reach out to the front desk if you have questions regarding your plan and referrals or authorization!
Insurance can be very tricky to navigate. This blog is a very broad overview of different insurance terms. When you schedule an appointment at Complete Physical Therapy, our front desk staff will call to get your individual benefits to take as much of guesswork out of it as we can!
– Written by: Meagan Nyhoff, PT, DPT & Michela Iwanski Pastuszak, Office Coordinator