Demystifying Health Insurance
Increasing access to care is important at Soulana Sanctuary, PLLC, so the following insurance providers are accepted:
Premera, Lifewise, Kaiser, and Aetna.
The world of insurance can feel like a labyrinth of unfamiliar terms and confusing procedures. Navigating this maze can be daunting, especially when it comes to understanding your mental health coverage.
Out-of-network providers, superbills, coinsurance – these terms can be enough to make anyone's head spin. But fret not, dear friend. Here's a practical guide to help you decipher the intricacies of insurance, empowering you to make informed decisions for your mental well-being and financial needs.
*insurance may be billed for Individual Therapy only.
Insurance Terms + Definitions
Understanding Your Coverage
The first step towards insurance enlightenment is understanding your specific coverage plan. This means familiarizing yourself with the terms and conditions outlined in your policy.
Insurance has all kinds of industry-specific language that can be hard to understand. Here are some terms you’ll encounter when navigating your health insurance coverage.
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A healthcare provider or therapist who is in network with an insurance company has a contract with that insurance company. That means that they are pre-approved to bill and work with your insurance company for services provided. In this situation, the provider bills your insurance directly and receives payment from them at a rate set by the insurance company.
When a therapist says “I take XYZ insurance” that means they are in network with that insurance.
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Out-of-network (or OON) providers are NOT contracted with your insurance company and cannot bill the insurance company directly. Most insurances have some OON benefits, and you will need to contact them to find out what they are.
How it works is you pay your therapist their fee at the time of service. Your therapist gives you a superbill (essentially an invoice) for services rendered at the end of the month. You submit that superbill to your insurance company and they reimburse you directly.
Please note that the reimbursement rate is a percentage of what the insurance company pays for therapy, NOT a percentage of the therapist’s fee. You will need to ask exactly how much they will reimburse you for therapy.
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A co-pay is a predetermined dollar amount that you pay a healthcare provider at the time of services. If your copay for mental health counseling is $40, then no matter what your therapist’s fee is, if they are in network with your insurance you would pay them $40.
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Coinsurance is similar to a copay but rather than a set dollar amount, it is a percentage of the service fee. If your coinsurance is 20%, your coinsurance would be 20% of whatever insurance normally reimburses for the service. So if the typical reimbursement rate is $129.17 then you would owe $12.92 for that session and your insurance will pay the remainder.
Coinsurance is a common feature in health insurance plans. It is used to help keep insurance premiums affordable by requiring policyholders to share some of the cost of their medical care.
Confused? Here’s a simple step-by-step breakdown:
1.) You pay your insurance premiums each month.
2.) You meet your deductible, which is the amount of money you have to pay out of pocket before your insurance company starts paying for covered medical expenses.
3.) After you meet your deductible, you pay a percentage of the cost of covered medical expenses, known as coinsurance.
4.) Your insurance company pays the remaining percentage of the cost of covered medical expenses.
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A deductible is an amount of money that you have to pay out of pocket before your insurance company will start paying for covered medical expenses. For example, if you have a $2,000 deductible, you will have to pay the first $2,000 of any medical expenses before your insurance company will pay anything.
It’s important to call your insurance provider beforehand so you fully understand what is covered before and after you have met your deductible. Your deductible resets at the first of the year OR when your term ends. At this point, you will start paying your deductible again.
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A premium is an amount you pay each month to be on your insurance plan. Generally speaking, a higher premium means lower deductibles, out-of-pocket maximums, copay/coinsurance, etc.
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An out-of-pocket maximum (OOPM) is the maximum amount of money you will have to pay for covered medical expenses in a given year. Once you reach your OOPM, your insurance company will pay 100% of the cost of covered medical expenses for the rest of the year.
OOPMs are a common feature in health insurance plans. They are used to help keep insurance premiums affordable by capping the amount of money that policyholders have to pay out of pocket for medical care.
Here’s a step-by-step breakdown of how OOPMs work:
1.) You pay your insurance premiums each month.
2.) You meet your deductible, which is the amount of money you have to pay out of pocket before your insurance company starts paying for covered medical expenses.
3.) After you meet your deductible, you pay a copay or coinsurance for covered medical expenses.
4.) Once you reach your OOPM, your insurance company will pay 100% of the cost of covered medical expenses for the rest of the year.
The amount of your OOPM can vary depending on your insurance plan. Some plans have a low OOPM, while others have a high OOPM.
The OOPM for a given plan is typically set by the insurance company and is not affected by your health status or the cost of your medical care.
Take your power back: check your coverage
If you’re planning to bill insurance for sessions be sure to call your insurance (phone number can be found on the back of your insurance card) prior to scheduling, and confirm your coverage. The best way to prevent unexpected bills or coverage issues is to reach out to your insurance provider and ask the following questions:
What are my mental health benefits (if any)?
How many therapy sessions does my plan cover?
Do you only reimburse for certain diagnoses, procedure codes, and/or session lengths?
Do I have Out of Network coverage?
What is the coverage amount per session? If they ask which code, CPT code 90837 represents the standard 53 minute session.
How do I obtain insurance reimbursement?
Is approval required from my primary care physician for receiving therapy services?
Am I covered for Telehealth (video) appointments?
Have I met my deductible yet? How close am I?
If I have a deductible, does it apply to mental health services?
Am I covered for associate licensed mental health counseling services (LMHCA)?
Make Informed + Empowered Choices
Once you have a grasp of your coverage, you can start making informed decisions about your mental health care. Here are some tips for skillful use of insurance.
Seek in-network providers whenever possible: This will help you minimize out-of-pocket costs.
Discuss out-of-network providers with your therapist: If you have a strong connection with a specific therapist who is out-of-network, discuss the possibility of seeking pre-authorization from your insurance company.
Understand your plan's mental health benefits: Many insurance plans offer coverage for a variety of mental health services, including therapy, medication, and hospitalization.
Communicate with your insurance company: If you have any questions or concerns about your coverage, don't hesitate to contact your insurance company. They are there to assist you.
Invest in yourself and your well-being.
You are worth it!
Remember, your mental wellness is paramount. Taking care of yourself is an investment in your overall well-being. Don't let the complexities of insurance deter you from seeking the support you need and deserve.
With a bit of understanding and proactive planning, you can navigate the insurance landscape with confidence and make informed decisions that prioritize your mental wellness and financial well-being.