Good question. Taking a moment to understand your insurance benefits will help you know what to expect. We suggest you familiarize yourself with these key terms:
In Network and Out of Network benefits
In network means that we have contracted with the insurance company to provide services for individuals who have that insurance. Out of network means we are not contracted with your insurance company. Some insurance policies include reimbursing you for some portion of an out of network provider’s services, although you typically are responsible for filing that claim with the insurance company in order to be reimbursed.
Primary and Secondary Insurance
Most people have only one insurance, a primary insurance, which pays a portion of the fee. Usually this is through the individual’s employer (or family member’s employer), purchased individually through the Affordable Health Care Act, or a government program.
Some people (mostly retirees) have a secondary insurance which can be filed after the primary has paid and which may pay an additional amount toward the fee). We are happy to file both.
Medicare Replacement plan
Individuals who qualify for Medicare have the option of selecting a replacement plan through a private insurance company, such as UHC or Humana. Reimbursement for services through these plans requires you see a provider who is both a provider for Medicare and for the private insurance.
Supplemental plan
Supplemental insurance plans are basically secondary plans which are filed after the primary is paid and may pay additional an amount.
Dual plan
Dual plans are Medicaid plans which are combined with a private insurance. We do not accept Medicaid or any dual plans.
Allowable
The allowable amount is the amount we have contracted with your insurance company for the service if we are in network. It is always less than our fee, and we agree not to bill you for the difference in order to be in that insurance network. We are not limited by an allowable amount if we are not on your insurance network.
Adjustment
The adjustment is the amount you do NOT have to pay in we are in network with your insurance.
Copay/Coinsurance
Copays and co-insurance refer to the amount you have to pay for each session. Your insurance plan will have one or the other. Your copay is the fixed amount determined by your insurer you have to pay for each session regardless of the cost of the session. A co-insurance is a percentage of the allowable fee you have to pay for each session. Providers are required by the insurance company to collect the copay or co-insurance as part of our contract with your insurance company.
Deductible
Your deductible is the amount you have to pay out of pocket before your insurance pays anything at all. The amount of deductibles vary widely from $0 to thousands of dollars depending on your plan. It starts over every year.
Out of pocket limit
The out of pocket limit refers to the amount you have to file on insurance before your policy begins to pay 100% of expenses. It starts over every year.