What are some common terms that explain my benefit coverage?
Copayment: An amount of money that your health insurance plan sets as your patient responsibility in the services you seek using your insurance. It is common for copays to range from $10-$60 (depending on your plan) and then the insurance pays the remainder. This occasionally does not go into effect until a deductible is met (see your specific plan benefits to be sure) . If you have a copay, this is usually the easiest and most predictable, straightforward coverage! We will simply charge your copay amount after each session.
Deductible: A deductible is an amount that you must pay out of pocket in a year before your insurance starts paying for services. Some plans have a relatively small deductible, like $500 and some have very large deductibles, such as $3,000 or $5,000. Typically cheaper plans have high deductibles. The amount we charge as the patient responsibility will be our contracted rate with your insurance company (this is the rate we agreed to accept from them when we agreed to be in network). When you are paying toward a deductible, you owe 100% of that contracted rate. Our contracted rate varies depending on the insurance company and the code billed (individual therapy, family therapy, assessment, etc.). Make sure you know what your deductible is and if you need to meet it before your benefits go into effect. You may have both an individual and a family deductible, depending on your plan. Once the deductible is met, your insurance company will then start paying for services and you will only have a copay or coinsurance. We cannot negotiate or reduce the amount you pay toward your deductible – it is an agreement between you and your insurance company, not between you and Family Roots. Part of our contracts with insurance includes charging the contracted rates that we agreed to with the insurance company. Please check your deductible and whether it applies to mental health services. This is the most common reason for unexpected patient balances. A deductible also resets each year, typically at the beginning of the year, so be prepared for that as well.
Coinsurance: Coinsurance is similar to a copay, except instead of paying a set amount (such as $20), you pay a certain percentage of the fee. So if our contracted rate is $100, for example, and your coinsurance is 30%, you would pay $30. Coinsurance is another common reason for unexpected patient balances and for patient balances that change. It is also why sometimes your balance might change from appointment to appointment. Similar to the deductible described above, we cannot negotiate or reduce your coinsurance amount – it is an agreement between you and your insurance company, not between you and Family Roots.
Explanation of Benefits (EOB): This is a statement that you receive from your insurance company explaining what was charged and what your patient responsibility is. We base our invoices to you off of what is listed as your patient responsibility balance in this statement from your insurance company. If you believe it to be inaccurate, please contact your insurance company.
In Network: A provider is considered to be “in network” with your insurance company if they have a contract with that insurance company to provide services. This means that we have accepted a specific rate from the insurance company for services we provide to its members, and we bill the insurance company directly on your behalf. Please confirm with your insurance company before your appointment that the provider you want to see is in network. Some plans only allow you to see specific providers or have “carve out” plans for mental health (which means that mental health benefits are under a different plan entirely).
Out of Network: An out of network provider does not have a contract with your insurance company and can charge any rate they want. While some out of network providers may bill insurance on your behalf as a courtesy, most of the time, an out of network provider will charge you directly and then you will need to submit a detailed receipt (called a “superbill”) to your insurance company, and then your insurance company will reimburse you whatever their allowed out of network reimbursement is. Some plans have out of network benefits and some don’t, so pay careful attention to your specific plan.