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Tackling Insurance. Get to know your benefits and how to get the most out of them!

It’s a new year and most insurance plans are about to reset on January 1st.  That means it is a great time to get refreshed with your insurance plan options and a great opportunity to set up a care schedule in 2020.  


Let’s talk about health insurance!!


It still shocks me how difficult it can be to navigate our healthcare insurance.  It wasn’t until I started taking courses on insurance billing that I truly started understand what healthcare benefits look like and how to use them. These classes were geared towards practitioners being able to bill insurance companies for their services but this basic knowledge is critical for anyone who has and uses insurance.  


I’m no expert, but I’m here to help you navigate. 
The best way to start this conversation is by breaking down terminology. So, here we go!


Deductibles.  Ugh.


Deductibles are specific dollar amounts that need to be met before insurance will kick in and start paying.  Basically, you pay out of your own pocket for the service until you hit your deductible total. You can think of them like financial hurdles.  Inconvenience for you, but convenient for the insurance company.  


In-Network versus Out-of-Network

Ask your provider.


Insurance plans generally have two separate levels of coverage: In-Network coverage and Out-of-Network coverage. 

In-Network providers have an agreement with your insurance company and that agreement dictates how much the insurance company is willing to pay for the services provided.  The perk of seeing an In-Network provider is that there is often no deductible to meet or a lower deductible.  And it is easier to assess the services without other complications or financial roadblocks (deductibles) applied by your insurance company. 

Out-of-Network means there is no dictated service agreement between the practitioner and the insurance company therefore the insurance company can pay whatever they like or not pay.  Often there’s a higher deductible to be meet before insurance will pay for out of network services. 

This is all very specific to your insurance plan.  Some plans have equal coverage for both In and Out of Network providers.  Some plans won’t allow you to see Out-of- Network providers, some plans reimburse the provider at higher rates when you are Out-of-Network.  It can feel like the Wild West sometimes.  This is where the importance of knowing the  specifics of your plan come in! 


Co-Pays and Co-Insurance.


Co-Pays are the amount of money that you pay upfront out-of-pocket to see your practitioner. This is considered your portion of the payment for services rendered. Insurance company will then pay the amount they decide to the provider. The amount paid to the provider varies from insurance company to insurance company and plan to plan.  What they pay is generally not equal to what is actually billed, but usually a percentage or predetermined amount. 

Co-Insurance is percentage based payment. With Co-Insurance the insurance company agrees to pay a percentage of the visit and you are liable for the remaining percentage. For example, you many have a 20% Co-Insurance, so you are responsible for 20%  of the visit cost and the insurance company will pay the practitioner 80% of the visit cost.   This number can be difficult to determine up front as the percentages are based on the actual amount the insurance company decides to pay, not what is actually billed by the provider. Often these are collected once the insurance company processes the claim, not at the time of visit.  Or if they are collected up front, then the amount collected is an estimate and the difference is settled later. 


Out-of-Pocket Maximum

(just imagine someone standing there, shrugging with their empty pockets pulled out of their jeans)


Out-of-Pocket Maximum is your friend!  It is a cap, or a limit on the amount of money you have to pay for covered health care services in a plan year.  Once you meet this limit, or total dollar amount set by the insurance company, your insurance company will pay 100%  of all covered health care costs for the reminder of the year.  100%!


Visit Limits and Maximum Coverage Amounts


Visit limits is pretty straightforward.  It is the total number of visits you are given every plan calendar year for that particular service.   Any visit after this number is now 100% your responsibility.  Again, this number varies greatly from plan to plan.   

Maximum Coverage Amounts is the amount of money the insurance company is willing to pay that for a particular service in a calendar year.  After this max is met, your are responsible for 100% of the cost.  

Are all these random words making a bit more sense?
I hate to complicate things, but I have to lay on another layer. 

Every Insurance company and/or plan determines co-pays/co-insurance based on are the services being provided.  Often this isn’t a problem,  but sometimes different modalities of care fall under different services.  For example, acupuncturists often do m ore than just needling.  We frequently include cupping and TDP lamps and massage.  Sometimes these modalities of care fall under Physical Therapy benefits.  This means there is often a separate or additional co-pay/co-insurance for those services.  For example you receive acupuncture and cupping in one visit. If your insurance company has a $15 co-pay for acupuncture visit and a $15 co-pay for cupping which falls under physical therapy then your total co-pay for that visit would be $30.  

Ever so often we also do office visits where we check in and evaluate how your care is progressing.  Sometimes these office visits have additional co-pays/co-insurance as well.  Again, it depends on your particular plan specifics. 

As you can see there’s a lot of variables.
And EVERY SITUATION is unique.

We do our best to check everyone’s insurance benefits and clearly communicate what we find teach and every patient  so you can make an informed decision on how to proceed.  

Often visit limits and deductibles, etc can limit access to care depending on financial situations. 

And when that happens or if you don’t have acupuncture coverage we often plans and packages that make access to care more affordable. 

Encourage you to reach out to us with any questions you may have so we can help you navigate. We also encourage you to contact your insurance company directly and get the information yourself so you feel empowered!



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