I am excited to accept most Health Insurance plans that provide acupuncture benefits in my practice. I find that doing so allows more people to experience Acupuncture. Many people are confused by their Insurance policies. I wanted to define some terms that my clients often ask me.
Premium: This is a monthly, quarterly or annual fee you pay for a health insurance policy. This is merely a fee for the policy and does not pay towards any medical expense you may have.
Preauthorization: Your insurance company may require you to contact them before partaking in some medical services. They will determine if the service is medically appropriate or necessary before they agree to cover the visit or service.
There are a few different types of Health Insurance out there. You may have one or a combination of a Fee-for-Service, Managed Care, Health Savings Account or Flexible Spending Account plans. Let me break them down for you and the terms that are often used with each.
Fee-for-Service Insurance: One of the more easy to understand types. This is where you go to the provider of your choice, either you or the provider submits to the insurance company an insurance claim for reimbursement. Only services (benefits) that are predetermined and listed on your summary of benefits will be covered.
Copay: An individual is responsible for a portion of the bill at time-of-service. This is determined based on the type of policy you have. Check with your insurance company to see what yours may be.
Deductible: Your insurance company may require you to pay a portion of the medical bill , generally up to a certain amount, before they will begin paying on claims. This can very depending on individual plans or family plans. It is important to review your policy to determine to what services the deductible is applied. Usually the higher your deductible, the lower your premium. If you want a lower premium, raising your deductible is an effective way.
Coinsurance: If the service is covered by your insurance plan, the insurance company will pay a portion of the expense. The amount you pay is called “coinsurance”. Let say, your insurance covers 80% of “the reasonable and customary charge” of Acupuncture services. You will be responsible for the remaining 20% of the fee. If the provider charges more than the “reasonable and customary charge” (as determined by the insurance company, you will pay the difference.
Out-of-Pocket Maximum: Once this amount is met in a calendar year, your insurance will cover your “reasonable and customary” medical expense in full.
It is important to fully understand your benefits. Even if your policy states that it covers Acupuncture, the fine print may stipulate specific conditions or procedures in which it will or will not cover. Some Fee-for-Service plans have coinsurance on some services and pay in full for other services.
Managed Care Insurance: Unlike Fee-for-Service Insurance plans, coverage is paid in advance. This plan provides comprehensive health services and rewards patients for using specific providers that belong to the Managed Care plan. These plans are often called HMOs, PPOs or POS plans.
HMO/PPO — These plans have contracted with health care providers to negotiate reduced medical charges. The providers who agree to this contract will be “in network”. Your premium affords you use of the services “in network” with less out-of-pocket expense. If you use a provider out of this network, you may pay a higher portion of the expense — potentially the full amount charge by the provider depending on the policy. This plan may still require copays, deductibles and/or coinsurance.
POS: Point-of-Service — A combination of Managed Care and Fee-for-Service Insurance. Often times these plans offer more flexibility than an HMO, but have higher premiums. Often times, you will need to get a referral from your primary doctor if you seek services outside of your network.
Health Savings Accounts: A tax-exempt account, used by the patient/consumer to pay for eligible medical expenses. It is often times linked to a high-deductible health plan. Employers and employees contribute to this account tax-free. This fund can only be used for medical expense.
Flexible Spending Accounts: This is a benefit where individuals can put aside a certain amount of their wages each year to pay for certain health-related out-of-pocket expenses not covered by other insurance plans. These are pretax dollars. Each year, the amount of money unspent is forfeited.
Insurance is a complicated topic. No doubt there are topics I haven’t even addressed in this post. I am more than happy to sit down with you and help navigate your insurance policy. What questions do you have?