Understanding Insurance

• What is a Deductible?
The deductible is the amount an individual must pay for health care expenses before insurance covers the costs. Many insurance plans require that their insured meet an annual deductible before their benefits can be applied. For instance, if your deductible is $2,000, you must pay that much out of pocket for covered health services before your insurance plan begins paying your health care costs. After that, they will pay their portion for care you receive during that year, or until you have received all the benefits your policy provides.

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• What does Co-Insurance mean?
Co-insurance refers to the amount of money that the patient is responsible for, after a deductible has been paid. Co-insurance is often specified by a percentage. For example, if the total claim was for $100.00 and your coinsurance is 20%, then you would pay $20.00 toward the charges for a service and the insurance company pays the remaining 80%. A few policies will cover a patient's care at 100%, and the patient will not be expected to contribute any dollar amount towards their care. Most insurance policies have either a co-insurance or a co-payment structured into their plans, and these co-payments, or co-insurance, vary per plan and per service.

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• What is a Co-Pay or Co-Payment?
A  co-pay refers to a specific charge you may have to pay for a particular service at the time of service. The most common co-pay is the flat fee you will pay for your initial exam and for any specific type of service. For example, some insurance plans have co-pays that can range from $10.00 to $50.00. Bear in mind you must meet any unmet deductibles amounts and coinsurance amounts in addition to your copay, dependent on your insurance plan. Not all polices include co-pays, just as not all policies include co-insurance. Some policies will require the patient to cover both a co-pay and a co-insurance, for example, an insurance company can require that the patient pay a $15.00 co-payment and a 10% co-insurance as well, as they will only cover 90% of the visit, after the co-payment. It can be very confusing, but we are more than happy to verify you benefits before you come in for care so you have a clear picture of what you will be responsible for.

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• What is meant by In-Network vs. Out of Network Benefits?
In-network refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts

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Out of network refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan. Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by a percentage of an individual’s insurance company.

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Many policies will also have separate deductibles for both in and out of network. Your deductible for in network doctors might be $500.00 and it might be met for the year. However, if you wish to receive care from an out of network provider, you will likely have to meet an out of network deductible that is separate from your in network deductible and often a higher amount, ie $1,000.00. Once you have met that out of network deductible, if you have out of network benefits, then the insurance can cover your out of network doctor visits as well. For example, a plan might have an in-network deductible of $500.00 with 100% coverage, and an out of network deductible of $1,000.00 with 70% coverage, meaning a 30% co-insurance will be the patient's responsibility, and the plan will pay 70% of the patient's office visit.

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Again, we are more then happy to verify your benefits and help you understand your specific coverage.

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• What is an Explanation of Benefits (EOB)?
An explanation of benefits is the insurance company’s written explanation regarding a claim, showing what they paid and what the client must pay. The document is sometimes accompanied by a benefits check. It will often have 'This is not a bill' written along the top, and include a lot of codes with various amounts divided into full amounts, discounted amounts, amounts applied to deductible or amounts that are the patient's co-payment or responsibility. Your insurance company will usually send you and EOB after the have processed a claim form a doctor you recently visited, and they will send an EOB to your provider as well.

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• What does a typical Insurance claim consist of?
A claim is a request for payment by your treating doctor to your insurance plan for covered items or services received. An example could include an initial visit to the doctor or treatments such as spinal manipulation, acupuncture, and other therapeutic procedures.