About insurance
Most of us visit our healthcare providers and hand them our insurance card, not knowing or understanding how much we’ll be charged, how much insurance will pay, or how it all works. When we ask questions, we’re often met with insurance words we can’t quite get our minds wrapped around. Hopefully, this can clear a lot of that up.
Let’s go over some insurance words and their definitions.
Your insurance premium is the amount you pay each month to have insurance, whether you use it or not. Usually, the higher the premium, the more benefits and less you’ll pay when you use your insurance, but not always.
The amount your insurance company and your healthcare provider agreed upon in a contract for a service provided when they are in-network. If your healthcare provider is not in-network, the insurance company must pay 100% of the charge, and that amount will be passed on to you within the structure of your benefits.
We may charge $170 for a session, but an insurance company might only pay $130. We agree to write off $40 of that charge.
A deductible is the amount you pay for services at 100% before you get to pay the lesser coinsurance amount. This is usually hundreds or thousands of dollars, and it starts over at some point each year depending on your policy.
Your deductible is made up of all of the payments you make for services at all of your healthcare providers.
Some people have an individual and family deductible. If your whole family spends enough money on healthcare costs, then all of you can benefit from it.
This is the percentage of the contracted fee you pay after meeting your deductible. The insurance may pay 80% and you would pay 20%. Usually, a person will pay 50% or less of the healthcare cost as their coinsurance.
This is a set dollar amount you pay for a healthcare service at the time of service, and you pay it every time you have that service. You don’t have to meet a deductible first.
What is a little odd about us therapists, is sometimes we are considered specialists and sometimes we are considered primary care providers. You may have a separate copay for each. Spoiler alert – specialists are more expensive.
This is when you have paid a set amount of money in healthcare costs made up of deductibles, co-insurance, and copays, and then your insurance company will pay for 100% of your healthcare needs for the remainder of the insurance year. It’s usually in the thousands of dollars, but surgery or hospital stay will quickly take care of it.
You can easily call the phone number on the back of your insurance card and ask the friendly human who answers, “What are my outpatient mental health benefits?” You can ask them what your deductible is, and if you have co-insurance or a copay. You can ask how much of your deductible has been met and how much is left.
Most insurance companies also have online access to this information, and you can look at the words they use to describe your benefits, which you now are empowered to understand.