The new year can bring many things. For those who have a calendar-year deductible health insurance plan, it means a deductible reset. If you’re unsure how a deductible plan works and how to navigate insurance coverage to meet your healthcare goals, here are some details for you.
What does a new deductible mean for you?
Let’s dig into that by defining a few terms from your insurance plan benefits guide.
Coinsurance: a percentage of costs of a covered health care service you pay after you’ve paid your deductible. You might think of this as cost-sharing. (1)
Copayment (Copay): a fixed amount you pay for a covered health care service. This typically is independent of your deductible, but sometimes goes into effect only after you have paid your deductible. (1)
Deductible: the amount you pay for covered health care services before your insurance plan starts to pay. (1)
Out-of-pocket maximum/limit: the most you have to pay for covered services in a plan year. (1)
How does it all work?
After you have met your deductible for the calendar year, you usually pay only a copayment or coinsurance for any covered services that occur before the end of the year. Typically your copay is independent of your deductible. After you pay your coinsurance, your insurance company pays the rest. And once you have reached your out-of-pocket maximum/limit, your health plan pays 100 percent of the cost of covered services.
As with anything, there are a few exceptions, including: copays, any charges for services that are not covered by your plan, and charges for services from a doctor who is out-of-network. These charges may not go towards your deductible either. Given this variability of coverage from plan to plan, Capital Chiropractic cannot guarantee anyone’s insurance coverage. Even if our office has attempted to confirm your benefits and eligibility, final approval of coverage is based on the explanation of benefits after the claim has been filed.
Unfortunately, it can become quite complex. Sometimes carriers will assign a copay to one service, a deductible to another, and a coinsurance to another service, all within the same date of service. Our office is unable to predict when this will occur and it can result in confusion down the road.
Contact a representative directly
When trying to gain clarity on what services your policy does or doesn’t cover, if a provider is in-network, or what is applied to your deductible, we recommend reaching out to your insurance provider directly. One of their representatives will be able to give the most specific details about your policy and coverage. We recommend using our Insurance Verification Worksheet to guide the call and obtain the information you need. Be sure to take note of who you spoke to, and when, and ask for a confirmation number or the representatives’ extension to verify your call.
We are here to empower
The clinicians and staff at Capital Chiropractic & Rehabilitation Center understand that our healthcare system can be overwhelming and complex, and that finances can have a massive effect on one’s ability to achieve their healthcare goals. We are here to answer any questions you may have about your coverage, though your own insurance company is the true authority on this subject. We hope to empower you with the information necessary to be able to make the best choices for your care.
Self-pay option at Capital Chiropractic
We use The Wellness Group to offer a self-pay option that simplifies and streamlines patient access to care. Patients who choose this option typically are uninsured, underinsured, or prefer the reliable, simple rates and full access to all of our clinic’s treatments. This is a great option for patients who are uninsured or underinsured. To learn more about this option, just ask at the front desk.
And again, we recommend using our Insurance Verification Worksheet to discuss any unanswered questions with your insurance carrier.
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