Insurance 101

The good, the bad, the confusing.

I’ll admit, when I first started at Sport + Spine almost five years ago I knew absolutely nothing about insurance and the benefits that came with it. Words like co-insurance, deductible and premium sounded like a foreign language that I thought I would never begin to understand. Since then, I’ve verified insurance plans and benefits for hundreds of people. I still won’t call myself an expert, but I do know enough that I feel confident explaining benefits and answering questions for prospective and current patients.

Having all of this knowledge has also helped me on a personal level. Now that my husband is in the tech/software industry I can expect a few job changes here and there. Since I have an understanding of benefits I know to ask about insurance coverage and premium costs before he even accepts the position. In this day and age healthcare costs keep rising and I need to know how an insurance plan is going to affect our finances before he moves forward.

Ultimately, the more you study your insurance plan the more you’re going to be able to take advantage of the coverage you have and be in control of your health!

When patients call to schedule their first appointment, one of the common questions I get is “Do you accept my insurance?” We are in-network with most major insurance companies, including Regence/BCBS, Premera, United Health Care, Aetna and MORE!  Every plan is different, therefore the cost per visit varies from person to person. It is purely dependent on the type of plan and benefits that you have.

Now, let’s go through some familiar terms in the world of insurance benefits:

What’s a premium?

A premium is the amount that a subscriber pays each month to have active insurance coverage. The cost of a monthly premium can vary based on the type of plan that is chosen. Some employers offer the choice between a high deductible plan and a co-pay based plan. Usually, the premium costs will be higher with a co-pay plan because there is the assumption that the patient will be utilizing the coverage more often. In most cases a high deductible plan will cost less per month to have, but your out-of-pocket costs will be higher at time of service. Therefore, it is important for you as a patient to research and decide how often you think you’ll be using your insurance benefits while balancing the overall costs.

What’s a deductible?

Your deductible is a specific amount of money that you, as the subscriber must pay before insurance will pay anything. Think of the deductible as a down payment for your year of insurance coverage. For example, if your plan deductible is $500 you will pay 100% of the contracted rate for any services rendered until that amount is met. After that, the cost of medical services is shared between you and the plan. Keep in mind that if there are multiple members on one plan (ex: employee plus spouse and kids) the deductible may be higher and shared between everyone.

What’s a copay?

A copay is a flat rate that you pay at the time of service. The amount does not change regardless of the number or type of services that are billed out. At Sport + Spine we commonly bill out both chiropractic and physical therapy codes. This is due to the combination of adjustments, soft tissue work and rehab exercises done during your visit. However, even though multiple types of service are being billed to your insurance plan only one copay will apply to your cost per visit (in most situations).

What’s a co-insurance?

Co-insurance is a percentage amount (dependent on your plan) that you pay at each visit. If your co-insurance is 20% that means that the plan will cover the remaining 80%. In general, the deductible will need to be met before the mentioned percentage kicks in. The total amount owed is determined by the contracted rates that the insurance company has set for the services we provide.

What’s the difference between calendar year vs. plan year?

It’s exactly like it sounds. A calendar year plan will run from January 1st thru December 31st and resets for the following year. On a rarer occasion some people will have a plan year which is usually based upon when a subscriber enrolls in their benefits (ie: July 1 2016-July 1 2017). If you’re an Amazon employee your coverage runs on a plan year.

Regardless of your plan, make sure you don’t let your insurance benefits go to waste. For example if you have a calendar year plan and it’s only June and your deductible has already been met take advantage of next six months and use those visits.

What’s a visit limit?

Visit limits vary from plan to plan. Your insurance company gives you a certain number of visits to use per year for each type of service (chiropractic, PT, Massage, acupuncture, etc.) Many plans offer separate visit limits for chiropractic and PT. Since we bill out both types of codes you’ll still be able to come to our office even if you’ve maxed out on your chiropractic limit.

What’s an out of pocket max?

Often times double the amount of your deductible, the out of pocket max represents the money that you have paid for medical services throughout the year. If and when you meet your max, the insurance plan will cover remaining approved services for the year at 100% (no patient responsibility). This rule does have a number of stipulations so I would encourage you to call your insurance company to learn more about this topic.

What’s an EOB?

An EOB stands for Explanation of Benefits. After your plan processes the claim (it usually takes 2-4 weeks) you will receive an EOB in the mail showing the services billed to your insurance and your patient responsibility.

 

There you have it; those terms are essentially the basics of every insurance company. Knowledge is power and I would highly encourage each patient, existing and new to dive into their benefits to learn as much as possible. If you still have lingering questions about your coverage don’t hesitate to ask team member at your clinic. And as always, the Sport + Spine team is here to help in any way we can so you’re able to get back to the things you love.