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Understanding Health Insurance

We get a LOT of confusion on health insurance. And it makes sense because this stuff is not made to be easily understood. I'm going to break it down a little so maybe you can have a better understanding of your health insurance plan.


All insurance plans typically have a "monthly payment"

For most people, we pay either out of our check or out of pocket for health insurance on the "marketplace." This ranges from a couple hundred bucks for an employer health insurance plan (if you're lucky), to a thousand+ dollars on the marketplace monthly. This is called a premium. You are paying to have health insurance and if you do not pay, they will remove you from their plan.


Copays

For some insurance plans, there may be a copay which could range from $5 to $100 per visit. Copays may vary for your primary care doctor, specialists and for mental health. You are required to pay this on every medical visit, and your insurance company covers the remainder of the amount due to the provider's office.


Why do I owe you money if I have insurance? Welcome to the Deductible.

I receive a LOT of confusion from people on bills they receive from us. If you have health insurance and you're paying monthly, wtf do I have to pay you for? Shouldn't the insurance pay you?! The deductible is a set amount of money you need to pay out of pocket before your insurance company agrees to pay anything. Not all plans have deductibles, but many do.


If you have a deductible, you are fully responsible for 100% of the payment until you reach whatever set amount your plan has on it. This could be as low as $500 a year, or this could be as high as $20,000 a year. If you are unsure if you have a deductible, PLEASE CALL YOUR PLAN AND ASK. You can also look online and see if you see "deductible" listed -- it should tell you the total amount you need to spend out of pocket, how much you have currently spent and how much more you need to spend to "reach the deductible."


Once you have "reached the deductible amount" -- or paid out of pocket enough money - your insurance company will now cover the services.



Coinsurance

At times, coinsurance means you might owe a certain amount of the total cost of the visit. The insurance company may pay 90%, 80% or 50% of the visit. You are responsible for the remainder. For some plans, after you meet the deductible, your plan may decide you still owe a percentage of the total of every visit.


Crazy amounts being billed?!

I've also had several questions about why people are being billed a TON of money for their visits when self pay prices are so low.


We have contracts with insurance companies, and insurance companies agree in advance on how much they will pay us (or how much you will pay us) per visit. The "amount billed" will always be super high - but the insurance companies just give us a negotiated rate which is significantly lower than that. It's just a weird game you play with them.


Insurance vs. Self Pay

Just because you have insurance does not mean you need to use it. We do offer a straight rate of $250/evaluation and $100/follow up for self pay for those who do not have insurance to keep things affordable.


You may notice if you have insurance, you are billed slightly more than this for these appointments. We have to go by the rates the insurance companies contract with us - and this varies by every insurance company and plan. It may end up being $123 for a follow up instead of $100 when you use insurance.


You need to weigh out if this makes sense for you or not.


If you have a $1,000/year deductible, that means you'd need ~9 visits with us before your insurance covers things for you. If you see other doctors or therapists regularly who use your insurance, you will meet this amount even sooner. It would make sense to use insurance in this case.


If you have a $15,000 deductible, see a therapist out of pocket and have absolutely no medical expenses other than visits with us, it might be more financially beneficial to just do self pay.


But that's bullshit. Why am I paying so much for health insurance if they aren't paying for shit?

Lol, welcome to our very broken American healthcare system. We're all in the same boat. Insurance companies are businesses that do not give a shit about you. All they care about is making themselves money.

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