Insurance is confusing for a reason. The more you don’t understand it, the less you will use it. This post is just a very general overview of what some of the insurance pieces are to kick off my explainer series on insurance. Your individual plan has its own nuances, and I’m going to give a few basic ways to call and try to get your own information if your insurance portal is not giving you the answers you need. CoPay This is the big one and one we usually look at. You have insurance, things should be covered and you just have to pay your copay right? Not always (this is the most common statement I make when talking about insurance). You MAY have a mental health copay, or you may not. A copay is usually a fixed amount that you pay each session for your services. That could be everything from $0 to $100. Often it will say a copay on the front of your insurance card-don’t always trust it. Especially for mental health depending on the plan we fall all over the place, primary care (BCBSNC), specialist, or our own behavioral health that is nowhere to be found on your card usually. CoInsurance Some plans have no copay but do have a coinsurance. Some plans have both. This is a percentage of the rate the insurance company has negotiated with each provider’s contract. That last statement is why at one mental health provider you may pay $24 and at another $34. That other provider has a better contract (honestly, nothing you need to worry about). This is the question you need to ask if you have coinsurance: With your contract, what would my approximate per-session payment be? Here is where it gets even more tricky. Most plans have a clear percentage- say, 25%. Some plans have not introduced a “variable rate coinsurance”. This means the amount you pay changes sometimes every time you use it. We honestly couldn’t tell you what it might be until we are paid. Sometimes insurance companies will change their reimbursement rates with providers-then your portion could go up or down depending on what the insurance company decided to do. Deductible The deductible is the big baddie of all insurance plans. Depending on your individual plan you may have a $0 deductible or up to $18,500+ prior to your insurance company covering ANY of your deductible-dependent services. This one is the one that gets most of our folks tripped up. We do our best to determine if you owe a deductible, but it says on every call line for insurance and every insurance portal we use: THE INFORMATION HERE IS NOT A GUARANTEE OF PAYMENT. PAYMENT IS DETERMINED AT THE TIME THE SERVICE CLAIM IS REVIEWED. Frustrating right? We think so. Some plans have mental health as a covered service, and you just pay your copay or coinsurance. Each plan is different, and it is SO important for you to know what your specific plan says. The best way to find out if this is something that will be in your way is to look on your insurance portal for a specific code or call the company and ask. I have some guidelines at the bottom of this post for you to use. If you have a deductible first plan, AFTER you meet your deductible, you will owe the copay or coinsurance your plan has listed. Also, your deductible resets each plan year. That means whenever your plan year starts again, so does that deductible. Out of Pocket Max This is the most amount of money you will spend out of your own pocket on deductibles, copays etc. for the plan year. This is often between $3,000, but I have seen up to $25,000. This is a tricky thing; some plans have an individual out-of-pocket max. Some plans have a family out-of-pocket max. You usually need to hit the one that is much higher to qualify and not have to pay anymore. Very important, and often where I get a number of angry, screamy phone calls. You owe any copay or coinsurance for the whole time until the insurance company has determined you meet your plan’s out-of-pocket max. We don’t make that decision. That is totally based on the plan you or your family chose for that year. This also resets at the start of each plan year. Tricky Things Some plans have a combined copay and coinsurance. That means you add the two of them together and that is what you will pay. This is not nearly as common in North Carolina but other states seem to have this as standard for mental health. If you have a copay of $25 and a coinsurance of 40% and your provider's contract says they get $100 per session. You are now paying $65 for the session while your insurance plan pays the rest. That variable coinsurance rate-honestly, we do not know what they expect until we get paid and that can often be up to six weeks after we started with you. We can look it up that day in the insurance portal but it may change the next day when the claim is filed. Sometimes it is based on how far away from your out-of-pocket max you are, sometimes its based on your deductible. Location-specific plans are becoming increasingly common. This means your provider needs to be in your specific state to provide the service and have it covered. Lots of providers, including a number of folks here at Abide Inclusive Therapy, have several state licenses. Those location-specific plans are even more tricky because your portal and our portals often do not tell us this is something to be concerned about until six weeks later; they just don’t pay us, and now you owe money for each session. Office and Telehealth differences. We are seeing a number of insurance plans also break how much you owe into where you receive your services. Here is the worst part, they often do not let anyone know that this is an issue on your plan unless you read your whole insurance benefits book or you know to ask. Tiered Plans. These guys are becoming increasingly popular. You reach out to your provider who takes BCBS-you have BCBS yay! However, the plan you signed up for is BCBS Blue Home UNC (for example, there are lots) if your provider is not also signed up as a preferred provider for this specific UNC BCBS plan your services will likely cost more because of a higher copay/coinsurance or a higher deductible to meet prior to coverage. This high deductible is often significant. If you are already working with a provider, make sure they take any of these specified plans, or it will end up costing you a lot, or you will need to try to find a provider who is in-network with that plan. Thank you, Yolanda. You have now confused me more-just tell me how much I am supposed to pay! Girl, I get it! Our practice has recently begun asking clients to call and verify their insurance as well, with an insurance verification form. This is because we are starting to get very incorrect information, which is stressful for everyone. If you get one amount and we get another, we honestly will have no idea until that first payment. Here is your best bet in clear steps for a phone call: Call the number on the back of your insurance card for members State when they ask why you are calling: “I am considering attending therapy and would like to know how much an in-network therapist would cost me with this plan for a CPT Code 90837 with a diagnosis code F4323.” If they say what NPI or ask other questions, just say you will be choosing an in-network provider and you just need to know how much it will cost before you begin to search. Say this even if you have a provider. The nuances of insurance contracts are so tricky; sometimes they cannot find us by our name or NPI number. Your individual diagnosis and session CPT code may not meet this but it is the most basic and innocuous way to get information that is likely to be accurate. Now ask, “Are there any specific plan adjustments I should know, like a difference between an in-office visit or telehealth?” This is also a good place to ask if you have a tiered plan or if your plan has any prior requirements to meet prior to mental health being covered. Now take the name and identification number of the person you spoke to. Send the information to your provider’s biller via direct portal message or email and say, “This is what they told me; does that look like what they told you?” For your insurance portal: Log in Check benefits Put in 90837 in-network If they ask for a diagnosis code F43.23 Take a screenshot and send it to your provider’s biller If you can’t find it, go ahead and call. ***Also make sure they do not need you to see a specific provider group. I have been seeing several plans lately that only allow mental health through specific companies, which are usually owned by the insurance company itself or a large tech company, for which you may have several therapists due to turnover. Common Warnings You will get sick of these if you read the whole series. Definitely pay attention to your plan nuances Remember that deductible-it is where people end up with a large bill If your insurance changes, let your provider’s biller know IMMEDIATELY. I cannot stress this enough. We don’t know your plan changed unless you let us know. Otherwise, we only find out when the old insurance denies the claims. If you have a high deductible plan, you could end up with a large bill you are required to pay. Please do not get angry with your provider or provider’s biller. We did not choose the plan. If you get a big bill, work with your provider to identify a reasonable payment plan. Therapists want to do therapy; we also find insurance frustrating and confusing.