Insurance 101

When clients schedule their first appointment, one of the common questions we 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.

We’ve created this dictionary of insurance terms to help you better understand the language of insurance and how it can work for you.


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.


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.


What’s a copay? A copay is a flat rate that you pay at the time of service. If you have a copay, 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 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).


What’s 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 coinsurance kicks in. The total amount owed is determined by the charges billed and contracted allowed amounts by your insurance company for the services provided.


Every so often, an insurance plan will have mixed benefits for different services. This may look like a copay for Chiropractic codes billed, and a coinsurance for Physical Therapy codes billed. If you have a plan like this, be sure to talk with your Client Experience Coordinator who can walk you through your specific plan.


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 2023-June 30 2024. 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!


What’s a visit limit? Visit limits vary from plan to plan. Your insurance company will oftentimes give you a certain number of visits to use per year for each type of service (chiropractic, PT, Massage, acupuncture, etc.). At Tangelo, we do our best to help you track these visit limits so you know before you run out of visits, but remember, if you’ve seen or plan to see another provider with the same specialty, be sure to let us know! Remember, you are paying a premium for your insurance so be sure to use your visits before your plan resets!


What’s an out of pocket max? Oftentimes the out of pocket maximum 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 out of pocket 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.


What’s an EOB? An EOB stands for Explanation of Benefits. After your plan processes a claim (usually 4-6 weeks), you will receive an EOB in the mail showing the services billed to your insurance and what your responsibility is. If you paid a coinsurance or copay 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!


My plan says authorization is required, what does that mean? If authorization is required for specific services, no need to worry, your Tangelo Team will do the heavy lifting! We will track authorization requirements and make sure we have everything we need to obtain authorization from your insurance. We may need a little extra paperwork from you from time to time, but we’ll be sure to stay on top of things so you can stay focused on your recovery!

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