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Understanding your Health Insurance

To better understand the terms of your plan, you first must understand the terminology.

Here are a few common questions regarding insurance lingo:

What is a deductible?

This is the total amount you must pay out-of-pocket before your insurance starts to pay. For example, if your deductible is $1,000, then your insurance will not pay anything until you have paid $1,000 for services subject to the deductible (keep in mind that the deductible may not apply to every service or visit you pay for). Furthermore, even after you have met your deductible, you may still owe a copay or co-insurance for each visit.

What is a copay?

This is a fixed amount that you must pay for a covered service, as defined by your health plan. Copays usually vary for different plans and types of services. You must pay this amount at the time of service. In most cases, copayments go toward your deductible.

What is a coinsurance?

This type of out-of-pocket payment is calculated as a percent of the total allowed amount for a particular service. In other words, it is your share of the total cost. For example, let’s say:

  • Your insurance plan’s allowed amount for an office visit is $100.

  • You have already met your deductible.

  • You are responsible for a 20% coinsurance.

In this situation, you would pay $20 at the time of service. The insurance company would then pay the rest of the allowed amount for that visit. Keep in mind that the coinsurance amount may vary from visit to visit depending on what services you receive.

What is the coinsurance for Medicare Part B?

Medicare Part B patients are responsible for a 20% coinsurance, which typically amounts to $20-25 per visit. If you have original Medicare as your primary insurance, but you also have a secondary insurance, the secondary payer becomes responsible for the 20%. In some cases, the secondary insurance also charges a copay, coinsurance, or deductible. We recommend contacting your secondary insurance carrier to find out.

So, how much will I owe for each visit?

If you have not yet met your deductible, then you will pay out of pocket per visit until your deductible is met. You will then owe any applicable coinsurance or deductible balances after we receive the Explanation of Benefits (EOB) from your insurance company.

Conversely, if we find that you have overpaid, we will refund you as soon as possible. As for copays—these amounts rarely vary, so if your copay for physical therapy visits is $10, you will owe $10 at each visit.

What if I can’t afford to pay these amounts as frequently as I need care?

Your health is our number-one priority. Therefore, we are happy to arrange a payment plan that works with your budget. That way, you can pay for your care over a timeframe that works for you. Simply ask to speak to our office/billing manager.

Some Notes

  • Most insurance companies offer several different plans or subsidiaries. So, two patients with Blue Cross Blue Shield, for instance, may have completely different benefits, and therefore, completely different financial responsibilities. Some plans have no copays or deductibles; others may have a $10,000 deductible. Furthermore, some providers may not accept all plans from a particular insurance. This is why it is crucial that you investigate the details of your specific plan.

  • If your insurance offers an online patient portal, sign up for it! These resources typically enable you to:

    1. check your benefits,

    2. track your deductible,

    3. see which providers in your area accept your particular plan,

    4. track your claims, and

    5. compare claims to your receipts from the doctor’s office (if they don’t match up, you can then follow up on any discrepancies).

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