5 Things You Need to Know About Insurance Coverage
We often get the question, "Will my insurance cover it?"
It seems with healthcare costs rising, insurance is now more expensive than it used to be with much less coverage. Sky-high deductibles, higher copays and coinsurance, managed care, and new pre-authorization requirements often make using your insurance more of a headache than a benefit.
To help you understand insurance coverage better, here are 5 things to be aware of with insurance benefits:
1. False Benefits- An example of a false benefit is when your insurance carrier says you have massage therapy benefits but if you read the fine print you will see that massage is only a covered benefit IF it is performed by a doctor or physical therapist but NOT a massage therapist. This is, in our opinion, deceptive. The benefit should not be called massage therapy if they won't allow the most logical provider (a massage therapist) to perform the service.
2. Insurance Allowed Amount- Allowed amounts are fees for services set by your insurance carrier. Your doctor's office has agreed to the allowed amount set by your carrier through a contract (this makes the doctor in-network with that company). The insurance carrier's allowed amount will supersede the doctor's office fees. For example, if our fee for an x-ray is $42 and your insurance carrier's allowed amount is $32, you will only be responsible for up to $32. On the flip side sometimes the insurance allowed amount is more than our fee and it would be less money for you to NOT use your insurance coverage. Yes, really!
3. Deductibles- a deductible is a yearly set amount of money which you must pay out of your own pocket before insurance will pay for any care. We commonly see deductibles above $1000. Deductibles may apply to all services or just certain services- each plan is different. Like the example above, if an x-ray is $42 and you insurance carrier's allowed amount is $32 and you have a deductible that applies to x-ray services than you will pay out of pocket the full $32. That amount will then be deducted from your yearly deductible. Once your deductible is met, your insurance will start to pay their portion of services. It is very common these days with such high deductibles to never meet it within a year. When this is the case it sometimes doesn't make sense to use insurance coverage and may even cost more if you do.
4. Copay vs. Coinsurance- A copay is a set, flat amount you are responsible for out of pocket for a given service no matter what that service's fee or allowed amount is. Using the above example again, if you had a $20 x-ray copay it would not matter that the doctor's office fee was $42 nor the insurance allowed amount was $32. You would only pay $20 out of your own pocket. Conversely, a coinsurance is a set percentage you are responsible for out of pocket which is a shared cost with the insurance company. This percentage can range anywhere between 10-50% as it varies greatly between plans. For this example, let's say you had a 20%
x-ray coinsurance (this means you are responsible for 20% of the charge and insurance is responsible for 80%). In that case, you would be responsible for $6.40 (which is 20% of the insurance allowed amount of $32).
5. Visit limitations and Managed Care- Some insurance companies will say you have unlimited chiropractic visits per year, but the fine print will say those visits must be medically necessary and pre-authorized ahead of time. This means you can't just come in randomly when you feel like it- you must have an accident or injury that causes a need to be seen which is not always the case when you want to be adjusted. Other companies will say you get 20 chiropractic visits per year, but the fine print will say after you use 3 visits, your doctor will have to ask if you can use more visits by submitting documentation showing you need more care. Then they may let you use 1 or 2 more visits and again the doctor will have to submit documentation to show you need more visits. These hoops to jump through take time and are frustrating for patients and providers. In our opinion, if your insurance company says you get 20 chiropractic visits per year, you should be able to use them when and how you like.
There is definitely a time and place for insurance coverage. We don't want to bash the system or only have negative things to say about it but we do want people to be aware that sometimes using health insurance is not always the best case scenario for them.
But don't worry. You're in good hands at Body in Balance as we do our absolute best to try and find out these frustrating insurance scenarios and communicate with you about them as soon as possible- many times before your first appointment. And whether you come in every now and then or you are a regular wellness practice member (someone who gets adjusted regularly to maintain a healthy spine and nervous system) we have affordable options for you like monthly care plan payments, massage packages, and more.
If you would like to know if chiropractic or massage may be a covered benefit on your plan, we are happy to help. Just give us a call or text at 360-713-8209