Important Insurance Terms and Concepts​

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• One way that health insurance plans control their costs is to influence access to providers. Providers include physicians, hospitals, and in our case: Acupuncturists and Massage Therapists . Insurance companies contract with a network of providers that has agreed to supply services to plan enrollees at more favorable pricing.  In short, we accept a lower rate than our cash rate in order to be considered "in network" with insurance companies. This benefits us, because patients are able to seek out our services through the insurance network and it allows us to provide care to patients that wouldn't otherwise be able to access these services. 

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• Annual deductible: The annual deductible is amount you pay each plan year before the insurance company starts paying its share of the costs. If the deductible is $2,000, then you would responsible for paying the first $2,000 in health care you receive each year, after which the insurance company would start paying its share.

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• Copayment (or 'Copay'): The copay is a fixed, upfront amount you pay each time you receive care when that care is subject to a copay. For example, a copay of $30 might be applicable for a doctor visit, after which the insurance company picks up the rest of the allowed amount. Remember, the allowed amount is only a fraction of what we regularly charge.

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• Coinsurance: Coinsurance is a percentage of the cost of your medical care. For a service that's allowed amount is $100, you might pay 20 percent ($20). Your insurance company will pay the other 80 percent of the allowed amount ($80).

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• Annual out-of-pocket maximum: The annual out-of-pocket maximum is the most cost-sharing you will be responsible for in a year. It is the total of your deductible, copays, and coinsurance. Once you hit this limit, the insurance company will pick up 100 percent of your covered costs for the remainder of the plan year. Most enrollees never reach the out-of-pocket limit but it can happen if a lot of costly treatment for a serious accident or illness is needed. 

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• What is means to be a 'Covered Benefit': The terms 'covered benefit' and 'covered' are used regularly in the insurance industry, but can be confusing. A 'covered benefit' generally refers to a health service that is included (i.e., 'covered'). 'Covered' means that some portion of the allowable cost of a health service will be considered for payment by the insurance company. It does not mean that the service will be paid at 100%.

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• For example, in a plan under which 'urgent care' is 'covered', a copay might apply. The copay os an out-of-pocket expense for the patient. If the copay is $100, the patient has to pay this amount (usually at the time of service) and then the insurance plan 'covers' the rest of the allowed cost for the urgent care service.

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• In some instances, an insurance company might not pay anything toward a 'covered benefit'. For example, if a patient has not yet met an annual deductible of $1,000, and the cost of the covered health service provided is $400, the patient will need to pay the $400 (often at the time of service). What makes this service 'covered' is that the cost counts toward the annual deductible, so only $600 would remain to be paid by the patient for future services before the insurance company starts to pay its share.