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Blue Mountains
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Co-pays, cost-share and deductibles

 

 

How do deductibles, coinsurance and copays work?

 

When both you and your health insurance company pay part of your medical expense, it’s called cost sharing. Deductibles, coinsurance and copays are all examples. Understanding how they work will help you know when and how much you have to pay for care. 

 

Deductible

 

  • A deductible is the amount you pay for health care services before your health insurance begins to pay.

 

Let's say your plan's deductible is $1,500. That means for most services, you'll pay 100 percent of your health care bills until the amount you pay reaches $1,500. After that, you share the cost with your plan by paying coinsurance and copays.

 

Coinsurance

 

  • Coinsurance is your share of the costs of a health care service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you've paid your plan's deductible.

 

Copay

 

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

 

 

Co-pays, and deductibles are due at the appointment.

 

 

The benefit phone number is sometimes listed on an insurance card as benefits, customer service or on the health insurance card following MH/SA  (mental health/substance abuse).

 

  • Clients should look on their insurance company website or call their insurance company and ask if I am a covered provider if they have a plan requiring providers to be contracted with the insurance company.

  •  If I am not a preferred provider they should ask if their insurance provides 'out of network benefits'.

  • If their plan covers 'out of network benefits' ask if they will cover a Licensed Professional Counselor.

  • Clients should call or make sure they have a referral or authorization if needed as we do not do that.

  • If you don't check your benefits and don't know what your coverage is, we will guestimate what your portion will be from our experience with your insurance company.

  • If you check your benefits, we will use your information. 

  • Insurances cover counseling with the individual and / or a family member. Do not worry about asking about family, marriage or couple's therapy. The terminology used by clients and insurance companies is different. If you are covered for therapy or mental health benefits you can bring anyone you want with you.

 

If your insurance says you need a medical diagnosis, don't worry. Stress to life changes or stages are a diagnosis. A person is having anxiety and/or depression or other symptoms whether or not the cause is from a relationship, the insurance company will cover the counseling when we are addressing the anxiety and depression or other symptoms that will improve while also addressing how these or other symptoms are caused by or how they impact a client's relationships. Medically covered symptoms can include and are not limited to: anxiety, depression, exhaustion, lack of motivation or focus, explosiveness, obsessions, compulsions, racing thoughts, mood swings, fearfulness, worry, nervousness, panic and substance abuse.

If a person is covered by two insurance plans, they MUST use their primary insurance before the secondary insurance can be billed for the amount remaining after the primary insurance company pays. If we receive inaccurate insurance information from a client and cannot correctly bill the current insurance company and thus the charges are denied, we will be billing the client directly and payment will be need to be paid immediately.

 

If two people are coming in together and they have different benefits, they will want to check and compare benefits to see whose coverage is best for therapy. Only one person's insurance can be billed for a session. You can schedule two sessions next to each other and then we can bill each person's insurance for one session so that we have more time in a double session.

If I am a provider for an insurance company and we have that insurance information from the client, I have to bill the insurance per my contract with the insurance company and have to go by what they allow charged.  

 

I cannot write off or waive any portion of what the insurance company says the client must pay.

   

The insurance company will NEVER pay for a no-show or late cancellation or telephone appointment or emails or phone calls or letters. These will have to be paid by the client at the next appointment or upon receipt of the bill - whichever occurs first.

 

 


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