The Low Down on Insurance
/Health insurance can be intimidating and definitely confusing. At Eastridge, we accept/are IN NETWORK with United Healthcare, Cigna, and Aetna. Each insurance company has different fee schedules and plan options. Here are the 5 things I think you should know to help you better understand health insurance (in a chiropractic setting).
Deductible is the amount you pay for health care services before your insurance plan starts to pay (partial or all) . Family insurance plans, often (but not always), have both an individual deductible, which applies to each individual family member, and a family deductible, which applies to all family members. Some family plans strictly have family deductible only, that means all family members are working towards one set amount. For some insurance plans, the deductible “does not apply”, which means that the patient does not need to meet any deductible and only the copay/coinsurance fee will be collected.
Copayments vs Coinsurance. Depending on your insurance plan you will have either a copay or a coinsurance. The difference between the two is, a set dollar amount vs. a percentage of the scheduled fee.
Copayment (aka copay) is a set dollar amount you pay, after your deductible is met.
ie: When your deductible is NOT MET - patient pays full fee according to your insurance company’s fee schedule, this payment goes towards your deductible. ie: $50 is paid by patient at time of service (United Healthcare fee) = $50 goes towards deductible.
When your deductible is MET - patient pays the set dollar amount according to your insurance plan. ie. If your copay is $20, that is paid at time of service, and your insurance company pays the provider the remaining ($30).
Coinsurance is a percentage of the scheduled fee you pay, after your deductible is met. Some coinsurance can even cover services at 100%, once the deductible is met (a lot of plans don’t pay 100% until the out of pocket is met).
Same rules apply as above if your deductible has not been met.
When your deductible is MET - patient pays the percentage of the insurance company fee. ie: 20% coins. of $50 = $10 which is what you would pay at time of service, and your insurance company pays the provider the remaining ($40).
To sum it up, if you have not met your deductible (individual or family), or out of pocket max, your copay/coins payment goes towards your deductible. Once deductible is met, the copay dollar amount, or the coinsurance percentage is used to determine what the patient pays to the provider.
3. In-Network means the provider is contracted with the insurance company (accepting their fee schedule) vs Out-of-Network means the provider does not have a contract with the insurance company (not accepting their fee schedule). In and out-of-network typically have two different sets of benefits (deductible, copay/coins, out of pocket). Patients usually pay less when using a provider in their network.
4. Fee schedule is the maximum amount/fee that is used to reimburse providers. For the three insurance companies we are in-network with, they each have a different contracted fee schedule. United Healthcare contracted rate is $50/visit. Aetna and Cigna are both contracted at $45/visit plus $13 for a processing fee, making it $58/visit.
5. Out of pocket maximum/limit, is the maximum amount you will pay out of pocket, once this amount has been met *, (via copay/coinsurance), your health plan will pay 100% of the costs of covered services. (* out of pocket does not include: monthly premiums, anything you spend on services not covered by plan, out of network care and services, costs above the allowed amount for a service that a provider may charge.)
A few other things to keep in mind is that most insurance companies have a visit limit per calendar/contracted year. Once you have reached your visit limit, we cannot continue to bill for services. Calendar year is January 1 - December 31 vs Contracted year varies but is a 12 month period.
Some reasons to use insurance vs. reasons to not use insurance:
To use:
Achievable deductible
Other family members helping reach deductible/oop
Copay/coins is less than our cash price
Not use:
High deductible
Limited number of chiro visits
Our cash price is less than your copay/coins
When I “check” your benefits, my goal is to gather all the information and help you figure out the best option for you. If you ever have any questions about your specific insurance benefits, I would be happy to look into it and explain further. Please feel free to email Sara at frontdesk@eastridgechiropractic.com
Sara - Eastridge Chiropractic Co. Office Manager & Billing Expert
