Health insurance benefits have undergone significant changes in the last decade, placing more financial burden on the individual; resulting, in higher premiums, coinsurances,and copays. Limited numbers of visits for services and/or a limited time frame in which you can use your benefits are commonly used components of current health insurance plans. In this blog we hope to provide information about these concepts and help you to understand how knowledge of this information can help you navigate your health care and physical therapy experience.
Let’s begin with some definitions:
Referral – Typically refers to an authorization initiated by a primary care provider for out-patient services or procedures. Most HMO plans require a referral from your Primary Care Provider (PCP). PCP selection is paramount for HMO patients, as many services need to be authorized through their office.
Prescription – A recommendation of care from an MD. It can be from a primary care provider, specialist, emergency care professional, etc. Many health plans that don’t require a referral will still require a prescription. Prescriptions are for a specific diagnosis and treatment plan, and must be used in a timely fashion. For plans that require them, any new injury will require a new prescription.
Premium – The periodic payment required to retain an insurance policy. This cost is usually split between the enrolled members and their employers. Premiums change year to year and have a direct correlation on the other costs associated with a plan. A lower premium generally means higher copays, deductibles, and/or coinsurances; while higher premiums can mean lower costs at time of care.
Coinsurance – A percentage-based cost sharing between an insurance company and a member. If your plan allows for $100 of care with a 30% coinsurance, then you’re responsible for $30. This cost is different from a copay in that it is based on a percentage of the contracted amount.
Copay - a fixed cost charged to the patient regardless of what is billed by the provider. Coinsurances and deductibles are variable depending on what is billed. Copays are a fixed rate but, like all costs, are subject to change annually.
Deductible – An amount of out of pocket costs that must be met prior to payment from an insurance company. For example, a patient with a $1,500 deductible will be responsible for the first $1,500 worth of medical costs that are allowed by their insurance. This cost per visit for therapy is variable depending on what the provider charges and the provider contract with the insurance company.
Out of pocket maximum – A ceiling on all patient payments. For example, a patient with a $2500 out of pocket maximum will not be responsible for any copays, coinsurances, etc after they have paid $2,500.
Time frame limits – many insurances place a set limitation on outpatient physical therapy. 60 day or 90 day limits are not uncommon. With these plans, patients are limited in the time they can receive care for a given diagnosis.
In the current state of health insurance, the individual subscribers are often required to pay out of pocket for some of the cost of services. If you, the consumer, have knowledge of your specific plan and its details, you can make more informed decisions regarding your care.
From the clinical side, after an evaluation, I am going to develop a plan of care based on what I think is best for dealing with whatever the problems are. This may be 1-4 visits per week for 2 to 12 weeks, depending on the diagnosis. If you, as a patient, have knowledge of your benefits, you can easily be an involved part of the plan development, ensuring comfort with your financial obligation.
We here at Joint Ventures Physical Therapy and Fitness pride ourselves on providing a high level of quality care in an efficient fashion, with your well being our top priority. Your knowledge of the details of your benefits will help us to help you achieve your goals in the most appropriate manner for you.