Your Insurance, Unraveling some of the Mystery

You may have received a shiny new insurance card from your employer, or you have purchased an individual plan. Either way, how do you know what your insurance will and won’t cover? Well, that is likely a question that will take you some time to understand. Hopefully this will unravel some of the mysteries and confusion about you unique health care plan. Know that when you arrive at your medical providers office, they will be tasked with confirming your unique plans benefits and limitations. This is sometimes a confusing revelation if you don’t know what your plan will and won’t cover. One thing that will be true? All plans are not created equal, and unless you take some time to know your benefits, it can be daunting and confusing experience. Here are a few words that you may encounter when you are learning more about your plan.

Deductibles: can range from $100.00 to as high as $10,000.00 annually. This amount needs to be satisfied before your insurance company will pay for any treatment. How it works? Each time you visit a doctor or specialist, you are chipping away at your annual deductible. Most plans will waive deductibles for preventive visits such as mammograms and annual physicals. Remember, each plan will vary as to how many visits will not be subject to deductibles, and how often.

Premiums: is the monthly amount that is paid to have an insurance plan, this is either paid by your employer or by an individual, or both. It often comes out of your paycheck directly and your employer pays to it to your insurance company on your behalf.

Co-insurance: is a percentage of the medical fees billed that will be due by the patient (you) each visit, usually about 10% to 20%. This amount comes due after your insurance company has paid their percentage to the medical provider, and after you have reached your deductible if applicable.

Co-pays: are a flat fee that you pay each time you see your practitioner. This fee can vary between doctor’s office visits and specialist.

Annual Maximum: is the maximum dollar amount or maximum of visits an insurance company will pay over the benefit of a year for all covered expenses. Usually this refers to a calendar year, but it can also be a plan year, so investigate which applies to your insurance plan.

Out of Pocket Maximum: is the total dollar amount a patient is required to pay for covered medical services during a specified period, usually one year. After this amount is met, ALL services will be paid at 100%. Some plans allow your copays to be included in this maximum, but usually it includes your deductible and or co-insurance payments only.

Number of visits: Some plans have a limit on the amount of visits a patient may obtain per year. After that limit has been reached, your insurance is likely not going to pay for your treatment you have received. This is often a limitation when you see a specialist, such as a physical therapist, and not your primary care provider.

HMO – means Health Maintenance Organizations: HMO usually means that you agree to use a specific team of health care professionals. In most cases you select one doctor, from a list of the members, who will serve as your Primary Care Physician. This physician now coordinates all of your health care, which means that he or she treats you directly and, when necessary, manages your referral to specialists.

PPO – means Preferred Provider Organization: 
With a PPO, you have the option of seeing a wider variety of providers, and you can usually refer yourself to a specialist in your network. 
When you choose to see a medical provider in your network your insurance, you will generally see a higher amount paid to your provider, which means less out of pocket to you. You may have out of network benefits, but check with your insurance company, not all PPO plans offer out of network benefits. Active Physical Therapy is a preferred provider for many health care plans offered in Washington State.

Our goal at Active Physical Therapy is to help educate you about your plan and advocate on your behalf. If you are not sure we have the correct insurance information, be sure to let us know if you think anything has changed with your coverage. Also, if you need help understanding your insurance, we are happy to break it down for you in understandable terms. 



Ultimately, you are in charge, and the more you know about your benefits, the more your insurance will work for you. 


Comments are closed.