New Year, New Insurance Plan: How Will Your Insurance Work at the Start of a New Year?

New year, new you, new insurance plan. Well, at least, the restart of your coverage–January 1 is the day most insurance plans restart (or set back to zero) their deductible amounts, their visit numbers and dollar amounts and out-of-pocket maximums. And when it comes to getting chiropractic care, you may have no idea what your coverage looks like, even if you’ve attempted an insurance verification yourself. The terms and figures aren’t helpful if you don’t know what they mean. That’s where we’ll come in to help.

What is an insurance deductible?

The deductible is an amount of money you must pay before your insurance begins to pay for claims. Some plans have a low deductible, like $233 (with Medicare) while others have very high deductibles, such as $10,000.

An individual deductible is meant for one person on the plan. If you have an individual deductible of $1000, when your spouse (who is on the same plan) goes in for wrist surgery, their costs do not go towards your individual deductible.

A family deductible is meant for the collective group of everyone on the plan that is in your family (on one subscriber’s plan). If you have a family deductible of $2000, your spouse’s wrist surgery costs will go towards the family deductible–hooray!

Note: Both deductibles will be on your plan. If a family deductible has been met, then everyone’s deductible is met. But: be on the lookout for exceptions.

What is an insurance copay?

A copay is a set amount for specific services. At the chiropractor, it will likely be the “specialist” copay or the alternative medicine copay. Alternative medicine includes chiropractic, acupuncture & naturopath. If you look on your card, you will see these copays (if you have them) listed by type. They typically include copays for office visits, ER, specialists, and x-rays. Prescription copays are sometimes listed as well, broken down in generic and specialized.

What is coinsurance?

After the deductible is met, your insurance covers a specific percentage of covered services, and you will pay the remaining percentage, adding up to 100%. So, if you have 15% coinsurance, your insurance will pay 85% of the cost of the covered service.

What is pre-authorization or a referral?

Some services and plans require pre-authorization (or pre-auth) prior to services being rendered. One example is getting an MRI, which many plans require pre-auth before getting this advanced imaging. If you have an HMO plan, nearly any specialized service (x-rays, orthotics) or specialist visit will require a referral from your general practitioner. Keep in mind: pre-authorizations expire or have a pre-set visit amount (check with your insurance). For example, they may approve 3 visits valid between January 18 and February 18 of the same year.

What is a Visit Max/Year?

For some services such as chiropractic, acupuncture, massage, or naturopathy, insurance companies set a limit on the number of visits per year they will allow / pay for. This number doesn’t roll over, so you will want to use as many visits as you need–use them or lose them!

What is a dollar amount per year?

Some insurance plans have a set dollar amount that can be used for chiropractic services, therapeutic massage or acupuncture. Sometimes this is a combined dollar amount with other services. A common combo is chiropractic and acupuncture both sharing a set dollar amount per year. It’s best to keep track of your care costs with your invoices, bills, receipts and explanation of benefits (EOB).

What is the out-of-pocket maximum?

This is the good part of insurance. It’s the most you’ll pay out-of-pocket. This figure combines your deductible, your copays, and your coinsurance costs. Once you hit this magic number, then you pay no more for covered services until your policy restarts. Most people only meet their out-of-pocket maximum from surgery, and extended hospital stay, or other chronic illnesses like cancer or dialysis.

What is in an Explanation of Benefits?

An Explanation of Benefits (EOB) is the paperwork you receive from your insurance after you’ve used medical services (a visit, a procedure, etc.). It shows what charges and payments went to which sections of your insurance, so you have a better understanding of the breakdown of your coverage. Check your deductible amount, your copays, and your coinsurance, as applicable. If you have questions about it, call your insurance, with your medical receipt and EOB handy. Make sure they line up.

What does “in-network” provider mean?

These providers and facilities are the ones that accept your insurance and are contracted to work with your insurance. Typically, you’ll pay less when you see in-network providers rather than out-of-network providers. (e.g. Your co-pay will likely be higher with out-of-network providers). It’s always best to cross-check whether your ideal provider or facility is in-network with your insurance either before or while you make your appointment so you aren’t hit with an unexpectedly high medical bill. The more you know!

Here are our in-network insurances that we work with:

  • Blue Cross/Blue Shield
  • Regence
  • Anthem
  • Providence
  • PacificSource
  • First Choice Health
  • Moda
  • Aetna
  • Meritain
  • Cigna
  • HealthNet
  • Humana
  • Medicare

What does out-of-network mean?

This indicates that your chosen provider or facility is not contracted to work with your given insurance. Be aware: some plans have separate deductibles for out-of-network providers and any payment made for out-of-network providers will not apply to the other deductible. Your copays and coinsurance will likely be higher to see an out-of-network provider. If they don’t have a contract with your insurance–you may be stuck holding the bag, and paying the cost for 100% of the out-of-network provider’s charges.

Please note: You still have an option to come to Element Chiropractic if we are not in-network with your insurance, but your costs may be higher. We will help you determine your cost upfront.

What are non-covered services?

Your insurance may not cover the cost of everything–and you’ll see these services listed out in your insurance documents and description of coverage. You may still elect to have these services provided or performed, but your insurance will not pay for any of it, and the cost will not go toward your deductible. If you choose to have non-covered services, you will pay directly for these services. A common example of non-covered service is Medicare does not cover for an examination by a chiropractor, so Medicare patients must pay for this directly.

What is secondary insurance?

This is an additional insurance plan that may cover your out-of-pocket expenses and any non-covered services. Sweet!

We can help!

Insurance can be so confusing. We know. We are happy to verify your coverage and benefits prior to your visit (if possible). We’ll do our best to determine what your costs may be. You, too, can call your insurance directly to get a clearer picture of your covered services and what the resulting expenses may be. Your health is certainly worth your attention–and the more you know about your insurance coverage, the more you’ll be able to use it to your advantage.