Understanding Your Insurance
Insurance companies have become quite complicated and difficult for even seasoned professionals to understand, and their rules, procedures, and plans are constantly in flux. The following document explains some general information about insurance plans and how they work, as well as information about my specific insurance situation in my practice.
Insurance plans are generally “managed” these days. This means that insurance companies dictate (to various degrees) how much treatment they will allow, how much they will pay for it, whom you can see for treatment, and often what kind of work happens in your treatment. Given this level of potential involvement, both subscribers of insurance (you) and providers of medical/mental health care make different decisions about what kinds of plans they wish to have.
There are generally two kinds of plans: HMO and PPO with a third, POS, that is somewhat of a blend. You should make it your job to be an informed consumer before signing onto a plan and before seeking health services, if you plan to use your insurance. Know that even within any insurance company (e.g. Blue Cross), there are many different plans with different arrangements and payment situations. Here are some basics you should know about the general types of plans:
HMO
These plans exercise the most control over your treatment, only paying for providers within a particular network, asking for frequent paperwork from providers documenting that you are engaged in treatment they dictate, and negotiating low rates for their services. With HMOs, referrals are necessary to see any kind of a specialist. Referrals are generated by primary care doctors, who serve as a gatekeeper. Many employers and subscribers choose HMO plans because the plans are the least expensive, but obviously at the cost of provider choice, your privacy, and your provider’s freedom to do what he/she believes to be clinically most appropriate for each individual patient.
PPO
These plans also have a network of providers who contract with them to accept rates for care, but they allow subscribers the flexibility to choose providers out of network and still obtain some insurance reimbursement for their services. The company’s preference is that you stay in-network, so they will charge the subscriber (you) more in the form of deductible and co-payment if you go out of network for treatment.
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POS
You have the flexibility to go out of network, as with a PPO, but you may need a referral to see a specialist for care.
Other terms you should know:
Deductible: This is the annual amount that you pay out of pocket before insurance will start to reimburse for any services you receive. Deductible amounts can differ vastly from plan to plan and tend to be higher when you are paying lower monthly premiums or when you go out of network.
Co-Payment: This is a required fixed amount per service that you pay out of pocket for each visit. Can either be a percentage of the fee or a dollar amount.
“Allowed amount”: This is the maximum amount that an insurance company dictates to be charged for a service by a contracted provider. If the provider is not a contracted or “in network” provider, he/she is generally not bound by this maximum billable amount and can charge full rate for services. When the provider is not in the insurance network, you may be responsible for the co-payment amount plus the difference between the “allowed” fee and the therapist’s actual office fee.
Insurance and my practice:
I am no longer accepting insurance in my practice. Payment for my services should be made to me directly for the full amount of the session each week. You are welcome to seek reimbursement from your insurance, and I am glad to be of assistance with that and will give you regular statements with the necessary information so you can submit them.
If you have an HMO plan, you cannot access any insurance reimbursement for my services but could elect to see me and pay out of pocket entirely.
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*You will be supplied with an estimate of my service costs for a specified time length and a legal notice (No Surprises Act) to make sure you are aware that you are choosing an out-of-network provider when you begin services with me. This notice is the result of legislation passed in 2022 for all health care providers.