Many health insurance plans provide coverage for various therapeutic treatments; however, the precise scope varies between plans.
HMO and PPO health plans typically require referrals in order to see specialists outside their network, while most individual and small employer policies sold on the Health Insurance Marketplace must cover mental illness.
What is covered?
Private health insurance and Medicare usually pay for mental/behavioral health treatments at similar levels as medical/surgical ones, making the process of accessing care simpler than ever. To determine whether your plan covers treatment, refer to its materials online or call its Member Services number – usually found on the back of your health plan card – and speak with an insurance representative regarding coverage and costs specific to your diagnosis (a collection of numbers and letters used by healthcare providers to identify medical treatments for billing purposes).
Some plans contain additional rules that can have an effect on whether a service is covered. For instance, an annual deductible and/or out-of-pocket maximum may apply (this amount must be paid before insurance coverage kicks in); then there may also be copays or coinsurance you owe when receiving covered services.
Whenever services aren’t covered by insurance, providers will usually provide you with a “Verification of Benefits,” also known as an EOB document that lists what your health insurer will cover and any out-of-pocket costs associated with them. If you don’t already have one, contact your health plan – many even offer online EOB resources like HealthPartners does – for one.
Many plans offer easy-to-use price transparency tools to help you understand what costs will be associated with different providers and locations, such as HealthPartners’ members being able to login online to their account and search for doctors, facilities or specialists – this can be especially helpful for budgeting purposes or knowing whether your desired physician is covered before scheduling an appointment – plus it allows for budgeting purposes as well.
What is out-of-network?
Opting to see an out-of-network provider often results in higher costs; these providers don’t have an agreement in place with your insurance provider and therefore usually bill for all treatments, although federal and state laws provide protection from being balance billed under certain circumstances.
Avoid out-of-network costs by selecting providers and facilities within your network. By doing this, you’ll enjoy more accurate billing with faster bill processing times – plus, your services will contribute more rapidly toward reaching your deductible or out-of-pocket limit.
In-network providers include physicians, hospitals, ambulatory surgical centers and other health care providers who have signed contracts with your insurance provider in order to offer discounted services at discounted rates and comply with its rules and regulations.
Some health plans don’t cover out-of-network care at all, while others only permit emergency coverage. If your plan offers reimbursement processes or limits for such services, these might differ accordingly.
Are You Worried About Unexpected Bills? To minimize unexpected medical bills, ask your physician to use in-network facilities or browse your insurance provider’s online directory. Also be sure to review your explanation of benefits to verify if your provider is correctly listed. Insurance providers should also include a “network status” section which indicates whether your doctor is part of their network or out. If your doctor falls outside of their network, your insurance company should indicate what amount you owe them based on what would have been paid out had he been in-network provider and send this information along with your explanation of benefits document. If your health care needs require you to visit a non-participating hospital or ambulatory surgical center, make sure that there is an acceptable medical reason. Also ensure that an in-network provider provides services so they can stabilize you before leaving the hospital.
What is a deductible?
A deductible is an annual payment you make towards healthcare services before your insurance begins to cover them. After meeting this deductible for the year, most plans won’t charge copayments or coinsurance; but these amounts may differ between plans so be sure to carefully examine what works best in your situation.
There can be advantages and drawbacks associated with both higher and lower deductibles, depending on your circumstances. A higher deductible could reduce monthly premiums but require you to have additional savings available for out-of-pocket expenses. If you don’t anticipate using your coverage often enough, a high deductible might work better – consider it before making your decision!
Not all health care services will count towards meeting your deductible, such as annual physicals and preventive healthcare screenings. If you plan to undergo any costly treatments or procedures in 2019, scheduling them before your deductible resets could maximize the benefit of your coverage.
Most health insurance plans typically feature both family and individual deductibles, with out-of-pocket healthcare costs accruing towards either of them until your family deductible is met; once reached, cost-sharing benefits of your health plan take effect.
Many individuals opt for higher deductibles as this enables them to save on initial out-of-pocket expenses while simultaneously lowering monthly premiums. Many also utilize tax-advantaged health savings accounts as a way of offsetting these higher costs, making this option particularly valuable for people living with long-term medical conditions and looking to lower monthly insurance costs.
What is a copayment?
Copayments are the fixed payments made when accessing healthcare services such as doctor visits, lab tests and prescription medication. Copayment amounts may differ for different healthcare providers and services (for instance emergency room versus out-of-network office visits) while copayments make up part of an individual’s total out-of-pocket costs which also includes annual deductible and coinsurance amounts.
People typically pay copayments until their deductible has been met; then the percentage of treatment cost that they are responsible for shifts to coinsurance depending on the details of their plan. While copayment amounts may change based on healthcare provider or medication choice, the percentage remains constant – such as when name brand drugs tend to require higher copayments than generic counterparts.
Understanding how copayments work is essential to planning healthcare expenses and making informed decisions about coverage options. A copayment also acts as a barrier-buster that facilitates care delivery. Copays may prevent people from seeking medical services when they don’t know exactly how much it will cost, so reducing or eliminating copays is an effective way to ensure everyone receives healthcare when needed. Health savings accounts (HSAs) can be an excellent tool for covering copayments and healthcare costs incurred under an HDHP plan. Keep in mind that HSA funds must be utilized within their plan year; any remaining balance will not carry over into subsequent years. For more information on HSA rules and regulations, consult your individual health insurance policy.
What is a coinsurance?
Coinsurance is a form of cost sharing between you and your insurer that helps divide responsibility for health insurance expenses evenly. Usually arranged as a fixed ratio, coinsurance will apply once you meet your deductible; after which, the same percentage of any covered service costs is taken out as coinsurance payments. Rates differ based on policy; you can gain more insight into them during open enrollment or by reviewing your benefits booklet. Coinsurance charges may also differ for in-network services than out-of-network ones as network providers often provide discounted coinsurance costs which help keep costs under control.
Copayments differ from coinsurance in that they’re set as fixed amounts rather than percentages of overall charges; typically this means prescriptions, doctor visits and other healthcare services that don’t apply towards meeting your deductible will incur them before reaching their deductible limit.
Your type of health insurance plan also impacts the coinsurance rate; HMOs tend to offer lower coinsurance rates while restricting access to doctors and facilities, while PPO plans offer more choice but typically come with higher coinsurance rates. Coinsurance typically begins being applied after meeting your deductible amount has been reached and continues until your out-of-pocket maximum for the year has been reached.
Keep in mind that it is best to utilize in-network services when possible; using more expensive out-of-network providers may increase your coinsurance rate and add up quickly. When searching for health insurance plans, work with one of our licensed agents so they can ensure you fully comprehend all terms and conditions of their policy coverage.
