Insurance 101

New year; new insurance? Even if your insurance is the same, it may have updated costs and coverage levels. If you’re planning to investigate your insurance coverage here is a quick insurance 101 lesson.

Not all health insurance plans cover chiropractic and massage. It’s important to remember that each company has many different plans so, unless you work for the same company, you may not have the same coverage as your friend with the same insurance.

Deductible

Your deductible is the amount that must be paid by you before your insurance starts paying. Depending on the amount and/or your health you may or may not meet your deductible. There is usually an individual deductible and a family deductible.

Let’s say John and Sally are married and they have 3 kids. If Sally meets her $400 individual deductible then the insurance will start paying on Sally but John and the kids still have to meet theirs. However, there is usually a family deductible that is less than all 5 of them combined. So if they meet the $1200 family deductible, in any combination, then the insurance will pay for all of them regardless if the individual deductible has been met.

Keep in mind that your deductible will get met at whoever sends their bill in first. If you see your MD on Monday and the chiropractor on Thursday and the chiropractor sends the bills in first, then that is who you will pay your deductible amount, or partial amount, to.

Occasionally, the deductible will be waived for specific services. For example, chiropractic care may be covered with just a $15.00 copay and the deductible does not have to be met.

Copay and Co-Insurance

Your copay and coinsurance combined are the portion of the bill you are responsible for after your deductible has been met. Some plans have a set amount per visit (co-pay) and some pay a percentage (co-insurance).

If your insurance covers chiropractic and massage at 80% co-insurance then you are responsible for a copay amount of 20% of the allowed amount.

If your insurance has a $20 copay then you pay $20.

If your insurance has a $10 copay and an 80% co-insurance then you pay $10 and 20% of the remaining charges.

Allowed amount

The allowed amount is the rate that the doctor’s office agreed to be paid for services when they became a participating provider. The allowed amount reduces the doctor’s fees based upon a contracted rate. This reduction is based upon each insurance company and plan so it can vary depending upon what insurance plan you have.

Out of Pocket Maximum

This dollar amount is the most you will pay out of pocket for medical expenses. Often times there are both per person and a family out of pocket max. So if you have surgery and pay $2000 for it and your out of pocket maximum is $2000, then the rest of your medical bills will be paid at 100% for the rest of the year. (Most of the time your benefit year is a calendar year but sometimes it’s different. For instance most teacher’s plan year goes from Oct-Sep.)

In Network vs. Out of Network

Your insurance company contracts with doctors throughout the country. These contracts spell out exactly how much the doctor will get paid for each service. This IN NETWORK rate (see the allowed amount above) results in savings for you and insurance company.

If your doctor is not on the insurance company’s list of contracted providers the doctor’s fees are not subject to a reduction. In other words, there is no contract limiting the insurance company’s liability. As a result there are often higher or separate deductibles and copay/co-insurance costs that you will be charged.

Summary of Questions To Ask Your Insurance:

1. Is Active Family or one of their doctors/therapists in my network?
2. Do I have coverage for chiropractic manipulation?
1. Does the deductible have to be met before the insurance will pay for treatment?
2. What is the copay for Chiropractic Manipulation?
3. What is the co-insurance for Chiropractic Manipulation?
4. Are there any limits? (A dollar amount or visit amount)
5. When does the policy reset? (Does it run Jan 1 – Dec 31 or some other schedule)
3. Do I have coverage for therapy? (ie. Electrical / Ultrasound)
1. Does the deductible have to be met before the insurance will pay for treatment?
2. What is the copay? Is it the same or separate from the chiropractic manipulation copay?
3. What is the co-insurance?
4. Are there any limits? (A dollar amount or visit amount)
4. Do I have coverage for massage?
1. Is there coverage under a licensed massage therapist?
2. Does the deductible have to be met before the insurance will pay for treatment?
3. What is the copay? Is it the same or separate from the chiropractic manipulation copay?
4. What is the co-insurance?
5. Are there any limits? (A dollar amount or visit amount)

Active Family Chiropractic is contracted with many major medical plans. Feel free to give us a call at 503-674-7894 with any questions on your insurance.