Insurance Empowerment

Do you ever feel like insurance jargon is a totally different language? Well, it kind of is. Here we will uncover some basics that will hopefully leave you feeling empowered about this consumer-based healthcare world we find ourselves teetering on the edge of. We will focus on defining some vocabulary and lining out some questions to ask your HR rep at work or insurance customer service. Or even better, you can find the answers yourself by reading through the benefit summaries your plan/administrator is required to deliver to you.

Insurance is a complex maze to navigate, sometimes a higher perspective helps to understand.

Insurance is a complex maze to navigate, sometimes a higher perspective helps to understand.

Allowable Amount: This is the contracted amount determined by the fee schedule from any given plan that is allowed to be paid for medical service codes. These amounts vary from plan to plan and sometimes determine why practitioners do not choose to contract under certain plans with lower allowable amounts. It is a way to control and predict costs for the insurance carrier.

Authorization: This is what is needed between the provider and carrier on your behalf to ensure that the services rendered are medically necessary based on what they see as appropriate for any given service. Medical Necessity Review (MNR) is another name they use. This varies by carrier and plan. It is your responsibility to understand if you need an authorization for treatment, keeping track of visits used and expiration dates. 

Benefit Maximum: This is a limit placed on how much of a covered service you have access to. Some plans have a $ amount, others have visit limits. The insurance allowable amount dictates how much you get out of a max $ amount. Visit limit is straight forward and it is litterally counting Dates of Service (DOS). Some plans have a maximum visit count and then the option for more upon MNR approval. Each member on your plan has an individual benefit max. Other plans combine services for a shared bucket of visits. Common for Acupuncture & Chiropractic to share a limit.

Copay: Your flat rate portion of a covered service. Usually between $5-$40.

Coinsurance: The percentage of responsibility shared between member and insurance carrier. 80/20 is common and how you will hear it phrased by the carrier, this means 80% of the allowable amount is insurance paid, and 20% is member paid.

*What's the difference between copay & coinsurance? Coinsurance often means that you have to meet a deductible first. Rather than a flat rate copay, your insurance carrier is allotting a percentage of responsibility based on the actual allowable amount that is payable to the provider. Some plans have both a copay and coinsurance. 

Contracted or On Panel: This is the same as "In Network". This means that your provider has filled out a bunch of paperwork and been checked out and approved by some board that administers credentialing for that specific carrier. This contract binds the provider to accepting the allowable amount for the plan/carrier. This allows you to visit the provider for a lower cost to you based on your member responsibility. 

Deductible: This is more common with most plans nowadays. The important thing to note is whether your deductible applies to the service you want. About half the time a plan requires the deductible to be met in order for your service to be paid by insurance. The deductible is met through you paying out of pocket for services that accumulate towards the deductible. It starts getting tricky when you read the fine print about what counts toward meeting your deductible or not. Hopefully, you have one of those plans that says, "deductible waived" next to the service you seek. Look for the indvidual deductible rather than family. There is also sometimes an out-of-network deductible operating from a separate bucket, see "Out-of-Network".

HSA/FSA/MERP/HRA: These are acronyms for Health Saving Accounts, Flexible Spending Accounts, Medical Reimbursement Plans, and Health Reimbursement Accounts. They are different versions of a similar thing, usually a separate account you and sometimes your employer contribute towards for spending on approved health related costs. Each one is goverened a bit differently in terms of strict spending and receipts needed. FSA is use it or lose it, while HSA rolls over every year and can be converted to a retirment fund once you reach a qualified age. 

Out-Of-Network: This means the provider is not contracted/approved with the insurance. Some plans have strict network requirements while others allow you to see providers in or out-of-network for the same cost. An out-of-network deductible may apply for these non-contracted providers.

Out of Pocket Maximum: OOP is the abbreviation you might see. This is the maximum amount that your plan allows to come out of your pocket in a given plan year. Once this amount is reached (usually if you have a surgery or a baby you will get there), your plan covers approved services at 100%, meaning your copay/coinsurance is $0%.

Important questions to ask about Alternative Care Benefits?

  • When is my plan year renewal date?
  • Does my insurance plan cover Acupuncture, Chiropractic, Massage, Naturopathy?
    • Do I have Physical Therapy (outpatient rehab) benefit? Is LMT covered?
    • Is my chosen provider In-Network?
    • What are my Out-of-Network coverages?
  • Does my deductible apply for these services?
    • Do these services accumulate towards my deductible?
    • Do my visits while meeting deductible count toward my benefit max?
  • What is my responsibility?
  • What is my benefit maximum?
  • Are there diagnosis limitations for covered services?
  • Have I reached my Out-of-Pocket Max?
  • Do I have an HSA/FSA/MERP/HRA to pay for non-covered expenses?

Did we leave anything out? Let us know if you need any help understanding your coverage. Email Questions to: