| The short answer is: probably, but it depends. There are many factors that impact what insurance covers and what they won’t. To help make things easier, let’s talk about some common third-party insurance terms.
HMOs and PPOs
Health maintenance organizations (HMOs) and Preferred Provider Organizations (PPOs) are the two most common types of insurance plans. HMO plans are focused on a primary care provider managing all access to healthcare. Plans are run through a medical group and to have care covered, you need to see providers who are in network with your medical group and your medical group will need to approve each service. PPO plans offer coverage of care through networks of healthcare providers without a referral needed, but your insurance plan may have other requirements like authorization or a prescription from a physician.
In-Network Care and Out-of-Network Care
Some insurance plans have both in and out-of-network benefits. Using the in network benefits you will see a healthcare provider that has contracted with your health insurance. Typically these benefits are a lower cost to you. Some, but not all, health insurance plans also cover out-of-network services. This means that you can see any provider, regardless of whether or not they are contracted with your insurance. If you see a provider that is out-of-network (not contracted), you will typically have to pay higher costs compared with an in network provider even if you have out-of-network benefits.
Referrals, Authorizations, and Prescriptions
These terms are very similar but not the same. Depending on your insurance plan, you may be required to have one of more of these in order for your insurance plan to cover services.
Referrals: This a written order from your primary care doctor for services. This order must be approved by your medical group. If you don’t get a referral, your insurance plan may not pay for services you receive.
Preauthorization: This is sometimes call prior authorization, prior approval, or precertification. It is a process and decision by your health insurance company to make sure that any services are medically necessary.
Prescription: This is sometimes called an order and is a written recommendation from certain healthcare providers for medical services. While some health plans do not require referrals or preauthorization for therapy services, they may require that a prescription be written by a physician.
Out-of-Pocket Costs
Let’s define some of the common terms for determining how much you will pay for care, and how much your insurance plan will pay.
Deductible: This is the set dollar amount that you must pay before your insurance plan will start to pay. For example, if your deductible is $1,000 for the year, you must pay for $1,000 worth of medical care before your insurance will start to pay a share. Deductibles can vary greatly. If you have a high deductible plan, you are eligible to create a health savings account (HSA). With an HSA, you can set aside money tax-free to help you pay for certain medical expenses.
Co-insurance: This is the percentage of costs that you must pay for services. For example, if your therapy visit has a bill of $100, with a 20% co-insurance you would be responsible for paying $20 and your insurance would pay the remaining $80.
Copay: This is a fixed amount you pay for a therapy visit. For example, if you have a $20 copay you would pay that amount and your insurance plan would pay for any remaining total regardless of the amount.
Out-of-Pocket Maximum: This is the most you have to pay for covered services each year. After you spend this amount on covered services, your insurance will pay 100% of the cost of any other covered services. For example, if you have a prolapse repair surgery that has a $1,000 out-of-pocket cost and your maximum is $1,000, any physical therapy visits after the surgery should be paid in full by your insurance plan because your maximum has been met. However, once the plan year starts over your deductible will reset. It is important to understand that not all medical expenses are applied towards your out-of-pocket maximum. Items like your monthly premium or any care that is not covered by your plan would not be applied.
This is an introduction to the common terms and concepts you’ll find in the third-party payor health insurance system, but you should talk to your insurance provider directly to determine what is covered and what your cost share will be. Your coverage is determined by the benefits of your specific plan.
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- Pelvic PT Evaluation of the Pelvic Floor Muscles with Dr. Samantha Richter, PT, DPT, WCS
Written by Emily Reul, PT, DPT |
