Insurance Insights from Allie!

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When thinking about an insurance plan for your child’s therapy in the New Year:

11/22

  • Is there a separate benefit for rehabilitation vs habilitation or is it combined?

  • How many visits do they allow in a calendar/plan year? 

  • Is this what they consider a hard max or will there be an option to request more once these visits are used?

  • Is authorization required? 

    • If yes, do they determine how many visits I get ongoing even though there might be 60 available? i.e. Evicore

  • What are the Deductibles & Out Of Pocket Max or is there just a set copay?:

    • Are they combined in-network and out-of-network or separate? Compare across all options of plans and figure out what best fits your family's budget when you think about how many visits your child may be using in the new year.

  • Are there any Exclusions:

    • Many Insurance companies have exclusions that are specific to diagnosis codes and only covered if related to, for example, Autism or Not covered if related to Developmental Delay etc. 

 

Always take notes at the end and ask is there a reference number for this call? What is your name? And make sure to write down the date and time of call. Stash away for potential future use. 

 

Remember… Keep us in the loop! 

If your insurance plan changes, alert INSPIRE PT ASAP.

If there is a need for authorization this will secure that we have a chance to request approval prior to your visit. Most insurance companies do not approve RETRO requests. Once we receive your new plan info, we will check this benefit and give you a quote based on estimated allowed amounts for services to help you better understand what you may spend a year. 

A Guide to Understanding Health Insurance Terms

 

Co-Pay

  • A fixed amount you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Co-Insurance

  • Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service. You pay co-insurance plus any deductibles you owe.

Rehabilitation

  • Rehabilitative services refer to healthcare services that help you improve your functioning and daily living skills that you may have lost when you  were disabled, hurt, or sick. Rehabilitative services can include psychiatric rehabilitation services, speech language pathology, physical therapy, and occupational therapy in a wide range of outpatient and inpatient settings.

Habilitation

  • Health care services that help a person keep, learn or improve skills and functioning for daily living

Deductible

  • The amount you owe for healthcare services your health insurance covers before your health insurance or plan begins to pay. Once you’ve met your deductible your insurance kicks in and starts paying a percentage of your services.  You will likely still owe a percentage (co-insurance) for future sessions.

In-Network

  • An in-network provider refers to your physical therapist that is considered part of a network of preferred providers for a specific health insurance plan. Patients usually pay less for services they receive from in-network providers than for services they receive from out-of-network providers. Providers offer a discount for their healthcare services in exchange for the insurance company referring patients to them. 

Out-of-Network

  • An out-of-network provider refers to your physical therapist that does not have a contract with your health insurance plan provider. Patients typically pay significantly more for services they get from out-of-network providers than for services they receive from in-network providers.

Out of pocket

  •  Refers to the largest amount of money you might pay annually for health insurance coverage. The out-of-pocket maximum includes any co-insurance, co-payments, and deductibles and is an extra amount of money on top of the premiums that you regularly pay throughout the year. Once you reach your out-of-pocket maximum, the health insurance company will pay for any and all expenses for the rest of the healthcare year.