Insurance 101

Ooohhh, insurance.

Some people love it, some people hate it. And mostly everyone who has it is a 50/50 mix of both.

I’ll admit, when I first started on the Tangelo team 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. I thought I would never begin to understand.

Nearly three years later I definitely wouldn’t define myself as an expert by any means, but I do know enough that I feel confident explaining benefits to our clients.

When most clients go 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 however, the cost per visit varies from client to client. It is purely dependent on the type of plan and benefits that you have.

The goal of this blog post is to answer the common questions about insurance coverage so you have more knowledge about what your benefits can do for you.

Now, I’ll walk you through some common terms in the world of insurance benefits.

PREMIUM

What’s a premium? A premium is the amount that (you) 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. Therefore, it is important for you as a client to research and decide how often you think you’ll be using your insurance benefits while balancing the overall costs.

DEDUCTIBLE

What’s a deductible? Your deductible is a specific amount of money that you, as the subscriber must pay before your benefits kick in for specific services. 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% for any services rendered until that amount is met. After that, the cost of medical services is shared between you and your insurance carrier. Thankfully, depending on your plan, the deductible doesn’t always apply…for instance, it may not apply to an office visit with your Primary Care Physician or favorite Tangelo Clinic (wink, wink). 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.

COPAY

What’s a copay? A copay is a flat rate that you pay at the time of service. If you have a co-pay, typically your deductible will not apply! The copay amount does not change regardless of the number or type of services that are billed out for each visit. At Tangelo we commonly bill out both chiropractic care 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 services are being billed to your insurance plan, only one copay will apply to your cost per visit (in most situations).

CO-INSURANCE

What’s a co-insurance? Co-insurance is a percentage amount (dependent on your plan) that you pay at each visit. If the co-insurance is 20% that means that the plan will cover the remaining 80% of whatever the total visit cost is. In general, the deductible will need to be met before co-insurance kicks in. The total amount owed is determined by the charges billed and allowed amounts by your insurance company for the services provided.

CALENDAR YEAR VS. PLAN YEAR

What’s the difference between calendar year vs. plan year? A calendar year plan will run from January 1st thru December 31st and then visit limits and deductibles will start over again. 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-June 30 2017. With that said, don’t let your insurance benefits go to waste!! If it’s June and you have a calendar year plan and your deductible has already been met, take advantage of next six months and get the care you need!

VISIT LIMIT

What’s a visit limit? Visit limits vary from plan to plan. Your insurance company often times will give you a certain number of visits to use year for each type of service (chiropractic, PT, Massage, acupuncture, etc.). Remember, you are paying a premium for your insurance so be sure to use your visits before your plan re-sets!

OUT-OF-POCKET MAXIMUM

What’s an out of pocket max? Often times the out of pocket max is double the amount of your deductible, but it can vary. This represents the maximum amount of money that you have to pay for medical services throughout the year. If and when you meet your max, the insurance plan will cover any additional approved services for the year at 100% (no client responsibility). This rule generally has a number of stipulations, so it would be advisable to call your insurance company to learn more about this topic.

EXPLANATION OF BENEFITS (EOB)

What’s an EOB? An EOB stands for Explanation of Benefits. After your plan processes a claim (usually 2-4 weeks), you will receive an EOB in the mail showing the services billed to your insurance and what the client responsibility is. If you paid a co-insurance or co-pay at the time of service, and your EOB says there is a “Client Responsibility” don’t fret, they don’t know you have already paid your provider!

Well, there you have it; those terms are essentially the basics of every insurance policy.

Knowledge is power and I would highly encourage each client – existing and new – to dive into their benefits to learn as much as possible. The more you know the more you can take advantage of the insurance you have and plan for the insurance you will need.

If you still have lingering questions about your coverage don’t hesitate to ask the Client Experience Coordinator at your clinic. As always, the Tangelo Team is here to help in any way we can so you’re able to get back to the things you love.