Deductible, Co-insurance, Out-of-pocket, what what what?!?!

By Chloe Sandberg, CC’s Staff

Deductible, Co-insurance, Out-of-pocket, what what what?!?!

                I am piggy backing a little bit off April’s blog last week discussing direct access and direct reimbursement. The other big question we get a lot of times, or at least the topic on many people’s minds, is how much is this PT treatment going to cost?? Here at CC’s, we bill all the treatments through your insurance provider as a courtesy to you. When you call to schedule an appointment initially, one our front desk coordinators take all your personal and insurance information, and then call to verify your insurance benefits. This is also a courtesy to you! Upon your first visit, all your insurance benefit information is available and discussed with you. Some of the things brought up include the in network vs out of network benefits, insurance percentage, deductible, copay, out of pocket, and any visit limitations present. Let me break down these can-be confusing terms below:

  • In network vs out of network:
    • In network benefits means that we as a provider facility have negotiated a contracted rate with your health insurance company
    • Out of network means we as a facility do not have a contract with that health insurance company or that particular insurance plan
  • Deductible:
    • This is the specified amount of money the insured person must pay before the insurance company will pay any money towards the charges/claim
    • Generally on a family plan, there is an individual deductible and a family deductible
  • Copay:
    • This is a fixed amount paid for each health care service at the time of the service
      • Common copay amounts include anywhere from $20 to $40 and are due at the time of your visit each time you are here
    • Out of pocket:
      • This is the most or maximum you as the insured will have to pay for any covered services in a plan year
      • Generally, once your out of pocket is met your insurance covers 100% of the charges/claims
    • Coinsurance:
      • This is generally broken into a ratio or percentage of what your health insurance will pay vs what you will pay AFTER your deductible is met
        • A common example is an 80/20 split, or once you have met your deductible your insurance will pay for 80% of the charges and you are responsible for the remaining 20%
      • It is also common that once you have met your out of pocket max, insurance will pay 100% of the charges
    • Visit limitations:
      • Some plans only allow for a certain number of PT visits in the calendar or contract year
        • Some plans allow for re-authorization, or we can submit for more visits if we use all of your allotted visits

Now that all of these insurance terms are swimming around in your head, I’m sure it is has you thinking about your own insurance plan/coverage. Perhaps you have already been a patient in our clinic and you have gotten a little taste of all this mumbo-jumbo. Or maybe you have been meaning to schedule an appointment but you are apprehensive about your insurance coverage or what your insurance coverage is for PT. Don’t fret friends! PLEASE give us a call right away and like I mentioned, our front office coordinators will take down all your information and verify your benefits so we are all on the same page. Everything works better if we communicate and move forward as a team, and this is no different 😊 Don’t let health insurance terms scare you. It does take a little education and memory to have a complete grasp on your coverage, but in the long run, we care most about getting you better!

Post Author: Chloe Sandberg

Chloe is a PT, wife, soon-to-be-mommy, MN to ND transplant, exerciser obsessed with food, Star Wars and Game of Thrones fangirl


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