Over the past three years, our model has evolved in many ways. The most impactful has been the switch to accepting health insurance because it has given us the opportunity to help many more people in need of our services.
One of the most frequent questions that we're asked is 'do you take my insurance?'
While the short answer is typically 'yes,' we've written this article to help you understand and navigate the jargon within your insurance policy. This will allow you to make more informed decisions when selecting an insurance policy, your healthcare, and how to work with us.
Before our daughter was born, I remember sitting down with my wife to choose the BEST insurance policy that would cover medical expenses for pre- and post-natal care. I remember looking at the website that compared these policies and feeling completely lost - and I'm in healthcare!!
In-network, out-of-network, premiums, individual and family deductible, out-of-pocket maximum, co-pay and co-insurance.
What do these mean? And what is covered?
First, let's define these terms.
In-network: when a healthcare provider is 'in-network,' it means that they have a contractual agreement with the insurance company to accept an approved reimbursement for their services. For example, a doctor may charge $150 for a service, but the approved amount may be $90 for that service. The doctor is required to accept that reimbursement and the patient will not be responsible for the difference.
Out-of-network: when a healthcare provider is 'out-of-network,' it means that they do NOTÂ have a contractual agreement with the insurance company and do NOTÂ need to accept an approved reimbursement for their services. In this case, a doctor may charge $150 for a service, and the insurance may reimburse $0, $150, or somewhere in between (depending on the policy). The patient may be responsible for the difference.
NOTE: Some policies have both in-network and out-of-network benefits. This means that your insurance will cover and/or contribute to covering both in-network and out-of-network services.
Premium:Â the amount that you pay for your health insurance each month. This cost will vary depending on the policy - including in-network and out-of-network benefits, deductible, and number of family members on the policy.
Deductible: the amount you pay for your healthcare before your health insurance begins to pay for services. For example, if your deductible is $1500, then you will be required to cover 100% of the cost of services until you've paid $1500 out-of-pocket. Once you'e covered the deductible, then you will share the cost with the insurance company by paying your co-pay or co-insurance.
Some policies have a single deductible for individuals and family, while others have separate deductibles. For example, an individual may have a $1500 deductible, while the family has a deductible of $3000. This means that any individual on the plan must cover 100% of the cost of services until you've paid $1500 out-of-pocket until you begin to share the cost with the insurance company for that individual or $3000 out-of-pocket until you begin to share the cost with the insurance company to cover all family members.
NOTE:Â Your deductible will reset at the end of each fiscal year. This means that the amount paid towards your deductible resets to $0 at the beginning of each year. For example, if your deductible is $1500, and you paid $900 towards that deductible in a given year - it resets to $0 and the beginning of the next year and you will be required to begin covering 100% of the costs of services again.
Co-pay: the set amount that you pay for a service - $10, $20, $50, etc.
There may be different co-pays depending on the service - office visits, specialist visits, urgent care, emergency room visits, and prescriptions. This amount applies if your deductible is or is NOTÂ met.
Co-insurance: the percentage covered by insurance once your deductible is met. For example, an 80/20 plan will cover 80% of the cost of services and you will be responsible for 20% of the cost of services once you've met your $1500 deductible. This applies until your out-of-pocket maximum is reached.
Out-of-pocket maximum: the maximum amount that you will pay out-of-pocket per year including deductibles, copayments, and coinsurance. Once you've covered this amount, your health plan will pay 100% of the cost of services. For example, if your out-of-pocket maximum is $3000, then your insurance will cover 100% of the cost of services after you've paid the $1500 deductible and $1500 in co-pays or co-insurance.
NOTE:Â Your out-of-pocket maximum will reset at the end of each fiscal year.
Now that we've reviewed the terminology - how can you work with EVO Health + Performance?
Well, you can click the link below to schedule a FREE Discovery Call to learn more about how we can help and what is covered by your specific insurance:
We look forward to hearing from you!
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