ART OF CARE
COUNSELING

Insurance Coverage - What you should know!

(Please note this is for informational purposes only and a general guide to help you ask your insurance provider the right questions)

 

When reviewing your insurance coverage, it’s essential to understand the following basic components:

1. Premium - The monthly cost you pay for your insurance plan, whether through an employer or individually.

2. Deductible - The amount you must pay out of pocket before your insurance begins covering costs.

• Example: If your deductible is $1,500, you must pay that amount before insurance starts covering certain services.

3. Copayment (Copay) - A fixed amount you pay for specific services (e.g., $30 for a doctor visit or $10 for prescriptions). Does not usually count toward the deductible (but in some cases it will - know in this case you will need to pay a designated amount directly to the therapist)

4. Coinsurance - The percentage of costs you share with your insurance after meeting your deductible.

Example: If you have an 80/20 plan, your insurance covers 80% of costs, and you pay 20% out-of-pocket.

5. Out-of-Pocket Maximum - The most you will pay in a year before insurance covers 100% of eligible costs. Includes deductibles, copays, and coinsurance (but not premiums).

6. Network Coverage - In-Network Providers: Doctors, hospitals, and clinics contracted with your insurance for lower rates. Out-of-Network Providers: Higher costs and sometimes no coverage at all.

7. Covered Services & Exclusions - Each plan has a list of covered services (e.g., mental health, substance abuse counseling. Some procedures or treatments may not be covered (exclusions).

8. Preauthorization (Prior Authorization)

9. Explanation of Benefits (EOB) - A statement from your insurer explaining what was covered, what was paid, and what you owe.​

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