Knowing your health insurance plan!


Welcome to the Dynamic Edge Physiotherapy blog!

Once a month we will be posting about a new topic that you may have questions about. Our topic this month is.... HEALTH INSURANCE! Health insurance can be a really confusing topic, but it is extremely important that you understand what your plan covers in regards to your coverage and benefits. We will be discussing some of the most common key terms, what they mean, and how they vary depending on your plan.

First things first, not every plan is exactly alike. Plan coverage is dependent on a multitude of factors. When choosing an insurance plan along with paying for a monthly premium, there are other costly factors to be aware of; your deductible, whether or not you have a co-pay or co-insurance, and your out-of-pocket stop loss. For the sake of this blog we will use this example: The “patient” has a $2,000 deductible, 15% coinsurance, and $4,000 out-of-pocket stop loss. They also have a health savings account, which we will talk about later.

First, we will discuss deductibles. Deductibles are relatively universal across the insurance world, as most plans will require a deductible for any medical service. Before the insurance will pay for anything you will be responsible for any medical costs within your deductible, and that amount can range from between $0 to $5,000+. Depending on your monthly insurance premium (the amount of money you pay for the insurance policy) the deductible may be higher or lower. Often times the higher the premium, the lower the deductible. Using our “patient’s” deductible as an example, they are responsible for paying $2000 worth of medical expenses before their insurance will contribute payments. This will include all medical procedures and visits ranging from yearly check-ups to MRI’s X-ray’s, etc.

After you have reached their deductible, the cost per visit will decrease as well. Depending on whether the insurance policy includes a co-pay or co-insurance, you will be responsible for paying a percentage of the medical costs. In our example, our patient has a 15% co-insurance. This means they have to pay 15% of the contracted rate between the provider and the insurance company. If the contracted rate is $100 per visit, then the patient has to pay $15, and the insurance company will pay $75. Every physician, physical therapist, clinic or facility, etc. will have a different contracted rate, which is why the amount owed may vary between them. A different clinic may have a contracted rate with the same insurance company for $85 per visit, which would change what the patient owes to $12.75 per visit.

Depending on the insurance policy, you may have a co-pay rather than a Co-insurance. A co-pay is a flat rate in which you will be responsible for every visit. The amount of the co-pay differs depending on the doctor. For instance, a primary care physicians (PCP), general care practitioner (GCP), will be a different co-pay amount than a specialist or a hospital. For example, if that same patient had a $25 PCP copay and a $35 specialist copay then any general practitioner they visit, they only have to pay $25. However, if they see a specialist like a neurologist or cardiologist (or any doctor that specializes in one specific field of medicine), then they pay a larger co-pay of $35. One positive to add to this though, is that many health insurances will cover one wellness visit per year without the patient having to pay their copay.

Patients will be responsible for paying their co-insurance/co-pay until the out-of-pocket stop loss (OOP) has been met. The OOP is the maximum cap a patient will have to pay before the insurance company will cover medical costs at 100%. Going back to our example, the patient has a $4,000 OOP maximum. This means that once they reach their $2,000 deductible, they still have another $2,000 to pay before their health insurance will cover everything 100%. This patient will pay 15% of every visit for all doctors’ visits, procedures, medical imaging, etc. The more often they go to the doctor, the quicker they will meet the OOP.

Now I mentioned previously that our patient has a health savings account (HSA). Some policies allow patients to put money away into an account, which they can then use towards their medical expenses. Typically, this money is removed from your paycheck before taxes. The amount added to the HSA is up to the patient, but if they do not add enough to cover their OOP maximum, they will be responsible for whatever the HSA does not cover. An HSA is a good way to ensure that they will be covered for medical expenses and won't have to worry about figuring out how to pay for them in case of an accident. If that patient has any unused funds at the end of the plan year, the money they saved will roll over into the next year.

Similar to the HSA, the flexible spending account (FSA) is owned by the employer rather than the patient. At the end of the calendar year, the remainder of the money in the account is given back to the employer. Unlike the HSA, the patient may have to provide receipts of the medical expenses to the employer.

Know before you go, our biggest tip to you is to call the number on the back of your insurance card before you show up to your appointment. The best thing you can do as a patient is to be aware of your benefits and know what type of services are eligible for you. Like we said previously, every plan is different. Some plans allow for unlimited services, whereas others may have restrictions or require authorizations. The insurance company will approve a certain number of visits as per medical necessity. If the requested visits were to get denied, you have the right as a patient to appeal the insurance company’s decision.

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