Understanding Your Insurance

How well do you REALLY understand your health insurance benefits? It is not uncommon for the majority of our patients to not fully understand their benefits and as a consumer, it can be very challenging to navigate the world of insurance to get answers. In an attempt to make this easier on you, below are a series of definitions and examples that will hopefully make things clearer. As always, if you have questions about your insurance and benefits, please do not hesitate to contact our office. Our billing staff are experts and will answer your questions

Premiums: A premium is the amount of money that you pay each month (or whenever your insurance designates) to have insurance coverage. Your premiums are NOT applied to your deductible and once you meet your deductible, you are still responsible for paying your premium. Premiums are what keep your insurance coverage current.

Co-payment (a.k.a. Co-pay): A co-pay is the fixed amount of money that you are responsible for paying to each medical provider at each appointment. This fixed amount varies with different plans and with various medical providers, but it should remain a flat fee for each specific provider within your plan year. For example your co-payment may be $20 when you see your family doctor but $30 when you see your cardiologist or physical therapist.

Deductible: A deductible is a flat amount of money that you, as the patient, are responsible for meeting before your insurance company will start paying on your insurance claims. The amount is determined by your insurance company and your plan and it must be paid every year. For example, if you have met $400 of your $500 deductible and receive a bill from your physician for $100, you have to pay the doctor the full $100; your doctor would then apply the $100 towards your deductible.

{Once the annual deductible is met, then your insurance company would either pay the remainder of your claim (if you have a co-pay) or a portion of your claim (if you have a co-insurance)}

Co-insurance: A co-insurance is NOT the same as a co-payment and is not a flat rate fee. If you have co-insurance with your health coverage, then you will be required to pay a percentage of your medical bills. That percentage is determined by your insurance company and your plan and may vary with each provider.

Out of pocket maximum: In addition to your premiums, this is the maxiumum you can expect to pay in a given plan year. This amount is also determined by your insurance company and your plan and can vary widely from plan to plan. Please note, however, that there are some insurance plans that NEVER pay at 100%.

To clarify a few things:

You may have a deductible and not have a coinsurance but will have an out of pocket maximum.

You may have co-insurance without a deductible but will have an out of pocket maximum.

You may have both a co-insurance and a deductible which means you need to meet your deductible first before your insurance kicks in and then you still have to pay a percentage. If you meet your out of pocket max, then your insurance will usually pay 100%.

Calendar year: If your plan runs on a calendar year, then it starts on January 1^st and ends on December 31^st

Contract year: If your plan runs on a contract year, then it will start and end on dates other than the calendar year. For example it may start on May 1^st and end April 30^th.

A common question that patients will typically have is how long can I come to physical therapy. Again this depends on your insurance and your plan but typically it will be one of four scenarios:

Your plan doesn’t limit your physical therapy visits at all
Your plan doesn’t necessarily limit your visits but they will only approve a certain number at a time and may stop approving visits at any given time
You have a set number of visits per calendar/contract year and your insurance will not give you any additional visits. This will renew when your insurance contract renews
Your plan gives you a financial limitation to physical therapy. For example, if your plan gives you $1000 towards physical therapy and they are paying $50 per visit, then you would have roughly 20 visits per year. The amount they pay per visit can vary greatly.

Some insurance companies have “in network” and “out of network” benefits. Simply put, if you choose a provider to do your knee surgery, for example, that is “in network,” you may receive a discount as compared to choosing a surgeon that is considered “out of network.”

This is a lot of information to take in but hopefully it has helped you better understand your insurance and your benefits. Ultimately it is your health and your responsibility to know your insurance benefits. The more you understand, the less likely it is that you will have unexpected bills and expenses. You should always contact your insurance if you have questions and as mentioned above you can always call our billing department.