Listed below is some common insurance lingo that I, as a billing specialist, have become very familiar with. I have provided an explanation of these terms with the hope that by knowing what these terms mean, you can better understand your insurance benefits, and in turn, get the most out of your insurance!

Deductible: A deductible is a set amount of money that you will have to pay before your insurance company starts paying toward your services. I have seen deductibles as low as $1000, or even a couple hundred, and I have seen them as high as $12,000. Each plan varies. When we tell you that you will be paying towards your deductible for your therapy visits, that means that you will owe the full amount of the visit, and your insurance will not pay anything until your deductible is met. Your deductible includes all the healthcare services you are receiving, so if you are also receiving services elsewhere or have had other doctor visits in the same year, all of those will also go towards your deductible, helping you reach that amount faster. A deductible is something that most insurance plans include, though I have seen a handful without one. Most often when you meet your deductible, the amount you owe will then switch over to coinsurance, which means you are only responsible for paying a certain percentage of the amount of the visit, and your insurance plan will start paying the rest. Some plans, though, will start paying for your services in full when your deductible is met, so make sure to read through your specific benefits so you know which applies to you. And don’t forget that your deductible restarts at the beginning of your service year.

Coinsurance: Coinsurance is the percentage of the service that you will be responsible for while your insurance company pays the remaining percentage. Typically, coinsurance kicks in after you have met your deductible for the year. For example, if you have a $1000 deductible and 20% coinsurance, and you are paying $100 towards your deductible each time you have a therapy visit, you would meet your deductible after ten visits for the year (assuming you are not receiving any other services for which you are paying towards your deductible). After that tenth visit, you would only have to pay $20 for each visit, and your plan would pay the remaining $80.

Out-Of-Pocket Maximum: Your out-of-pocket maximum is exactly what it sounds like: the maximum amount that you will pay towards covered healthcare services in a calendar year. This even includes copays! So if you have a $20 copay for PT but you meet your out-of-pocket max for the year, your plan will cover your visits in full, and you will no longer have to pay that copay at each visit. However, you have to remember that it only includes covered services. If you run out of visits or have a procedure completed that is not covered by your plan, you will be responsible for the full amount of that visit, even if your out-of-pocket maximum has been met for the year. This is why it is so important to call your insurance plan to verify the service you are going to receive is covered before you actually receive it! And don’t forget, that just like your deductible, your out-of-pocket maximum will restart at the beginning of your service year. 

Copay: A copay is a set amount of money that you can expect to pay for each visit. For example, if you have a $25 copay for a doctor's visit, you know you will have to pay $25 each time you visit your doctor’s office. Typically the only time you would not owe this amount is if you have met your out-of-pocket maximum for the year. However, as a disclaimer, you should double-check with your plan that copays are included in the out-of-pocket maximum. Once again, each plan is different!

Benefit Year (also called Service Year or Contract Year): This is the timeframe that you are allotted to use your visits and meet your deductible and out-of-pocket max. Most insurance plans run on a calendar year, which means everything restarts on January 1st. However, there are some plans that run July - June, June - May, or even December - November. Your plan could be different, which is why it is important to be aware of what your benefit year is. Call your insurance company to find out for sure.

Visit Limit: A visit limit is exactly what it sounds like. Many plans have a set limit of how many therapy visits it will cover each benefit year. Sometimes plans will combine the therapy visits. For example, your plan might state it allows “90 combined visits per calendar year”, which would mean you have 90 visits to use between OT, PT, and ST. Or it might only combine PT and OT visits, and ST has its own visit limit. Or maybe you have 20 OT, 20 PT, and 20 ST visits for the year. Some plans don’t specify a visit limit. Each plan is different, which is why it is so important to reach out to your plan to verify any limits that apply to the services you are receiving.

When discussing insurance, I always use non definitive terms (as you may have picked up on from above) such as “typically”, “sometimes”, or “usually”. As I have stated many times already, each insurance plan is different, and as providers, we only have limited access to your benefits. You as the covered individual have full access to your benefits, which is why it is so important for you to understand how your specific plan works. If you have any questions about your benefits or how much you will be paying for a specific service, we are always happy to discuss that with you to the best of our knowledge, but ultimately, we will always encourage you to reach out to your health plan directly, as they are the best source of information for you. You can reach your insurance plan at the Customer Service number on the back of your insurance card, and you can reach us here in the the Wilson Pediatric Therapy Billing Department by call or text at 859-475-4305 (extension 5 if you are calling) or email at billing@wilsonpediatric.com from Monday - Friday, 7:30am-6pm.