Understand Your Health Insurance

January 13, 2021
Renee Limon
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The words fun and insurance rarely go together. So while fun might not be an attainable goal, we can try to avoid frustration by understanding the basics and common insurance pitfalls. If your new year's resolution is to understand your health insurance, you're in the right place.

Understand Your Health Insurance

First step: learn the lingo!

Does calling your insurance company put you into procrastination mode (or worse, the red zone)? Relatable. Keep in mind that insurance uses a lot of big words, and once you understand key terms, you’ll be able to speak fluently. Know that insurance customer service agents are pretty nice when customers call. It’s their job to answer your questions, explain your benefits, and keep you happy enough to choose their insurance again during open enrollment! Many also have user-friendly websites with chat functions if you’d prefer not to talk over the phone.

Key terms (these will be on the test)

  • Plan year: most plans follow a calendar year. So if copay amounts or number of visits change, or a need for prior authorization, it’ll start on January 1, and end on December 31. It's less common that your annual benefits fall into a different date range, so it's always good to ask.
  • Deductible: the amount you are responsible for paying before your insurance starts paying. Deductible amounts vary widely by plan.
  • Copayment: a set amount for a specific type of visit. For example, any doctor visits might cost $20 for your plan, and specialist provider visits cost $30.
  • Coinsurance: instead of a copayment, your insurance may require you to pay a percentage of the contracted allowable for the visit, such as 10 or 20 percent. This amount is different for each insurance plan. With coinsurance, usually, the deductible needs to be met before your payment amount switches to the lower coinsurance amount.
  • Contracted allowable: each year, each insurance plan we are in-network with sets the amount of the maximum they will pay for specific services. If you have a coinsurance amount and have met the deductible, this is the amount your coinsurance is being calculated on. If you have a copayment, you don’t really need to pay attention to this part.
  • Network: Health insurance plans reduce your costs by working with in-network providers. We are in-network with Blue Cross/Blue Shield, Moda, PacificSource, and Kaiser by referral only. All other plans are out of our network. If you are out of our network, you would pay our private pay rates. (link)
  • Prior authorization: some plans require authorization or approval before they will pay. When that’s required, we do some paperwork, usually at the time of evaluation or your first visit, and share data with your insurance plan on why the visits are medically necessary. You may receive a letter explaining that a certain number of visits have been authorized. This is often less than your plan offers for the whole year. We take care of this on our end and get you involved only if something goes wrong, such as when visits aren’t authorized.

Want to learn more? Check out this glossary of easy to understand health insurance terms. They also show clear-cut scenarios of how different plans with copayments, deductibles, and coinsurance affects your bottom line.

Empower yourself with your plan’s particulars

We are often asked what is a good plan to sign up for if you know you’ll be having regular speech and occupational therapy visits. Honest answer: every plan is different. Talk to your friends and family. Call the number on the back of your insurance card. Read the helpful handouts from your HR department. It’s such a personal decision based on what type of care your whole family will need during the year. We encourage you to use our handy reference sheet for calling your insurance company to drill down on specific questions for speech and OT coverage. If your plan provides you with a benefits booklet, take a moment to read the section on "Habilitative/Rehabilitative Care," paying close attention to the fine-print exclusions.

If you want to put your knowledge to the test, challenge yourself by tracking your medical documents. You can save money and feel more in control of the plethora of insurance statements that come your way.

What about online therapy?

Due to the pandemic, most insurance plans pivoted quickly to allow reimbursement for online therapy visits last year (even if they had not allowed online therapy before). Make sure you know if your plan will continue to allow online therapy in 2021. We encourage you to call your insurance company as soon as possible. It’s better to know sooner rather than later what you or the insurance company will be responsible for paying for this year. Many insurance plans are changing if and how they will reimburse for online visits. We have no way to predict these changes and often won't know the changes until your claims are fully processed. It's entirely possible that visits that were covered in 2020 will not be covered in 2021. This means that your out of pocket expenses could increase. Please understand that these are not changes that we are making. Having to explain that your insurance company is making you pay more for our services is never fun.

We are a small but mighty staff at The Hello Clinic. We are always open to answering your questions about your benefits and coverage. However, our clinic continues to function with fewer staff members than at the start of 2020, and this impacts the amount of time we have to track and check your benefits. We encourage our clients to partner with us to ensure you understand your benefits, how your deductible works, and how many visits you have each year.

Whew! That was a lot of information, so thanks for sticking with me. Give your insurance a call. You got this!