If you have health insurance right now, you’re one of the lucky ones. If you understand how to maximize it, then you’re one of the clever ones. Yes, you’ve probably noticed that the healthcare system in America is a bit whacked out these days. With standardized healthcare on the horizon, commercial insurance companies are scrambling to find ways to increase their profits, and FAST, before the federal government begins regulation. Because of their rapidly changing policies in an effort to capitalize at every turn, it has become more vital than ever for patients and healthcare providers to become super savvy about their health insurance plans.
So, it’s time to roll-up your shirt-sleeves and dive into some jargon. The following list of terms will help you understand how any changes in your policy will affect you and your ability to receive care. Remember, most individuals will have slightly different insurance plans, even with the same insurance company, so make sure to call the customer service number on the back of your insurance card and ask about your benefits.
Benefits:
‘Benefits’ simply refers to what kinds of things your insurance company will pay for. You might use the term to ask if specific types of treatment are covered by your plan. For example: “Do I have massage therapy benefits?” is something you should ask your insurance company before you receive any massage treatment.
Deductible:
This is the most important word for you to understand and the most important amount for you to know when it comes to a policy. A deductible is the amount of money you must spend out of pocket before your health insurance will cover anything. Generally, you will pay 100% of all of your health insurance expenses until your deductible is met. Depending on your plan, this number can range from $0-$10,000.
Claim:
An insurance claim is a formal request for payment from an insurance company in accordance with an individual’s benefit policy. This term is not frequently used for normal health insurance because the provider’s office generally submits claims directly to the insurance company so you don’t have to worry about it. For Motor Vehicle Accidents (MVA) and Labor and Industry (L&I) injuries, however, knowing specifics about your claim is crucial. For most MVA and L&I cases you must have a claim not only submitted, but APPROVED before you can begin receiving treatment. You’ll also want to verify that the claim is open and is being paid. Make sure you check with your claims manager or adjuster (the person in charge of your claim) to determine if there is a dollar limit on your claim as well.
In/out Of Network Providers:
Providers usually have the option of contracting with specific insurance companies. Should they choose to do so, they will be considered in-network for that insurance company. For the patient, seeing an in-network provider will usually result in a lower co-pay. Often-times, an insurance company will not cover treatments from a provider who is not in-network. Make sure you ask your provider if they are in or out-of-network before receiving treatment. Our providers at Advanced Medical Massage are considered in-network with most major insurances companies. But when calling to ask about your benefits, remember that the clinic itself cannot be credentialed as a provider, rather it’s the individual therapists who are each credentialed under their own name.
Combined Rehab Benefits:
Some plans have combined benefits for rehabilitation services. Any dollar or number limits you have for Combined Rehab Benefits will apply to all treatments you receive that fall under rehabilitation services. If, for example, you are seeing a physical therapist in addition to receiving massage therapy, appointments with both practitioners might count towards your annual visit limit. The limits and services included may differ between insurance companies, so it’s important to ask about this one.
Co-pay:
Your co-pay is a set amount that your insurance company has decided you will pay each visit after your deductible is met. Some plans do not have a co-pay but many do. The amount of the co-pay may change depending on whether or not the provider is in or out-of-network. Note: a co-pay is different than co-insurance. (see #7 below)
Co-insurance:
The co-insurance is a percentage that is your portion of your expenses to pay. It is not due at time-of-service, as are co-pays. Rather, you will receive it after you insurance company has been billed. Many times you will have different co-insurance amounts for in-network and out-of-network services.
Maximum Annual Limits:
Most insurance plans will have a dollar or number limit on the amount of a specific treatment you can receive each year. Your plan may, for example, allow for 20 visits to massage therapy clinic each year. If you go over this limit, your insurance company will not pay for the treatment and you’ll be stuck with the whole cost. Make sure you ask your insurance company about your annual limits before receiving treatment!
Maximum Out Of Pocket Expense:
Ever wonder if your insurance company will pick up the whole tab? Well when you have reached your maximum out pocket amount your insurance company will cover 100% of your healthcare ( as long as they are covered and in your policy as such)….as long as you haven’t received your maximum lifetime benefit already. (see #10 below for maximum lifetime benefit)
Maximum Lifetime Benefit:
This is exactly what it sounds like. After you reach your maximum life-time benefit, it’s time to go searching for a new health insurance company, if they’ll even consider you. The maximum lifetime is often around $2 million dollars and, as you can imagine, is reached by receiving treatments for a serious illness such as cancer, or multiple surgeries, etc.
For some of you, these terms are old hat. But for many patients we speak with, they stumble in the insurance wasteland. We hope these explanations will help to empower you in getting the most out of your health insurance, and hence the most out of your health care. If you have any further questions, even if you feel like it’s a “stupid question”, don’t hesitate to call our office: 360-527-9566.