UNDERSTANDING HEALTH INSURANCE TERMS

Navigating your way through health insurance benefits can be a challenge. It is very important to understand the terminology especially when deciding which benefits will work for you and finding a plan that will best meet your needs. This brief glossary will provide insight for some of the more common terms when dealing with health insurance.

co-insurance: in indemnity, the monetary amount to be paid by the patient, usually expressed as a percentage of charges.

co-payment: in managed care, the monetary amount to be paid by the patient, usually expressed in terms of dollars.

consumer driven health care (CDHC): refers to health plans in which employees have personal health accounts such as an health savings account, medical savings accounts or flexible spending arrangement from which they pay medical expenses directly.

deductible: the portion of medical costs to be paid by the patient before insurance benefits begin, usually expressed in dollars.

denial: refusal by insurer to reimburse services that have been rendered; can be for various reasons.

eligibility: the process of determining whether a patient qualifies for benefits, based on factors such as enrollment date, pre-existing conditions, valid referrals, etc.

exclusions: services that are not covered by a plan.

flexible spending arrangements (FSAs): an account that allows employees to use pre-tax dollars to pay for qualified medical expenses during the year. FSAs are usually funded through voluntary salary reduction agreements with an employer.

gatekeeper: in managed care, it refers to the provider designated as one who directs an individual patient's care. In practical terms, it is the one who refers patients to specialists and/or sub-specialists for care.

health maintenance organization (HMO): a form of managed care in which you receive your care from participating providers.

health savings account (HSA): a savings product that serves as an alternative to traditional health insurance. HSAs enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.

managed care: a method of providing health care, in which the insurer and/or employer (policyholder) maintain some level of control over costs and utilization by various means. Typically refers to HMOs and PPOs.

member: a term used to describe a person who is enrolled in an insurance plan; the term is used most frequently in managed care.

non-participating provider: any health care provider or organization that does not have a contractual agreement with an insurance company to provide care to eligible patients for a contracted or discounted fee. Patients can receive services from non-participating providers if they have out-of-network benefits as a part of their insurance plan or if they wish to pay cash for the service but they will miss out on in-network discounts. (Same as "out of network provider")

open enrollment: a set time of year when you can enroll in health insurance or change from one plan to another without benefit of a qualifying event.

out-of-pocket: money the patient's pays toward the cost of health care services.

participating provider: a health care professional or organization that has a contractual agreement with an insurance company to provide care to eligible patients under certain defined conditions and often at discounted and/or contracted fees. (Same as "in network provider")

payer: the party who actually makes payment for services under the insurance coverage policy. In the majority of cases, the payer is the same as the insurer. But, as in the case of very large self-insured employers, the payer is a separate entity under contract to handle the administration of the insurance policy.

policyholder: purchaser of an insurance policy; in group health insurance, this is usually the employer who purchases policy coverage for its employees.

preferred provider organization (PPO): a form of managed care in which the member has more flexibility in choosing physicians and other providers. The member can see both participating and non-participating providers. There is a greater out-of-pocket expense if member sees non-participating providers.

premium: the cost of an insurance plan shared by employer and employee.

provider: one who delivers health care services within the scope of a professional license.

reimbursement: refers to the payment by the patient (first-party) or insurer (third-party), to the health care provider, for services rendered.

PHYSICAL THERAPY AND YOUR INSURANCE

A Patient's Guide to Getting the Best Coverage

The best way to take care of your health is to take an active role in your own health care. To do this, you need to know about your options and your rights as a patient. Patients across the country are becoming better educated and demanding more and better options from their health insurance companies. The right to physical therapist services is an important option, and it is your right as a patient.

Federally qualified HMOs are required to have physical therapy in their benefits packages.

In most states you may see a physical therapist without a doctor's referral, but be sure to check your health insurance plan to see if physical therapist services are covered without a physician's referral.

What You Can Do to Improve Your Physical Therapy Coverage

Talk with your employer/benefits manager. The employers who contract and pay for employee health care plans often have the most influence with insurers. Employers are interested in keeping their employees on the job and their premiums low, so providers who can help employees prevent injuries and avoid recurrence (as well as promote a healthy lifestyle) have particular appeal to them. Arrange a meeting with your human resources director or whoever is responsible for negotiating the terms of the company's insurance plan.

Ask your human resources director or insurance company the following questions to determine if your current benefits package gives you access to appropriate physical therapy services:

1. Is your physical therapy benefit "bundled" with those of other providers of care? Physical therapy services should be listed separately in the benefit language so that access to necessary services is not compromised.

2. Does the benefit language permit access to physical therapists for each condition during the year? Benefit language should permit treatment of more than one condition in a calendar year (eg, ankle fracture in January and low back injury in July).

3. Does the benefit language permit access to physical therapists for each episode of care? A person may require more than one episode of care for the same condition. For example, someone with arthritis may receive physical therapy intervention for knee weakness in an attempt to avoid surgery. While this is often successful, some patients may still require surgery for the knee condition (eg, total knee replacement), which may require post-operative physical therapy treatment. The benefit language should support each "episode of care."

4. Does the benefit language ensure coverage that facilitates restoration of function? Benefit language that restricts physical therapy care to a 60- or 90-day period imposes an arbitrary limit on recovery. In determining an appropriate physical therapy benefit that will allow an individual to return to his or her previous level of function, benefit language should reflect the normal amount of time that it takes to recover from an injury or from surgery.

5. Does the benefit language ensure coverage that promotes functional independence for those with chronic conditions? Someone who has a chronic condition may need to be seen periodically by a physical therapist. The physical therapist will determine if the individual's home program, equipment, or adaptive devices should be modified. (For instance, children requiring orthotic devices will need modifications to those devices as they grow.) Benefit language should ensure that someone with a chronic condition may receive the kind of care that promotes personal safety and the greatest degree of function possible.

Choosing a Health Plan

Millions of Americans are offered a choice of health plans through their employers, but the question is "What makes a good health care plan?" Here are some things to consider when choosing a health plan.

• Are you choosing a plan simply because it is the cheapest? This may not be the best way to go. Some inexpensive plans have a high deductible and no comprehensive coverage.
• Is the plan accredited by the National Committee on Quality Assurance? This is a good indicator of quality.
• Are your current doctors and specialists in the plan? If not, make sure you will be able to see a certain provider or specialist, such as a physical therapist, without too much added expense and difficulty.
• Is physical therapy coverage adequate? If you should have an injury or illness requiring rehabilitation, you will need a plan that offers an unlimited number of visits to a physical therapist or that allows for the number of visits to be extended if needed.
• Are there lifetime limits on benefits? If so, you could face a serious financial crisis if you or a covered member of your family suffers a major illness or injury.
• Does the plan have an out-of-pocket maximum? In this case, once you have paid a certain amount (usually several thousand dollars) the plan would cover the rest.
• How does the plan handle grievances and appeals? The procedure should be simple, timely, and accessible.
• Does the plan permit use of out-of-network doctors, specialists, or hospitals? Called "point-of-service" option, this would allow you to see a provider, such as a physical therapist, who is not in your plan. There may be an additional cost, but it may be worth it.
• What is the plan's disenrollment rate? A high rate of members leaving the plan annually may indicate customer dissatisfaction.

COPAY v. OUT OF POCKET v. DEDUCTIBLE

Until working in this field, I was entirely guilty of not understanding my health insurance; but it seemed so basic! When I got into the workforce for the first time, a few friends and I sat down and reviewed our benefits with each other. Everyone around me understood what everything was/what everything meant, so I just played along and acted as if I understood mine, too. 

This, coming from a person who is not afraid to ask for help, makes me assume there are more of you out there. Maybe your partner handles insurances or finances, maybe they're the policy holder and you're classified as a dependent on their insurance. Whatever the reason, I'm just going to explain the difference between a few things some of our patients tend to get mixed up, or confused over. 

First things first: Coverage Types 

Most of the time, you're looking at two different sections: medical and dental. Under medical lies anything you can imagine; ranging from doctor's visits, to physical therapy, to maternity, to mental health. Dental will include all aspects of dental, including regular teeth cleanings, orthodontists, oral surgery, etc. 

Next: Your Insurance Card

Your insurance card carries all the information you need to get details regarding your benefits and coverage. On the back (maybe even the front) of the card, there will be a customer service line. It may have two, one being for providers. That line is meant for the doctor's office, only. You call the regular customer service line. 

• You'll need to know your name, date of birth, and the member ID number. That's usually found on the front of your card.
• From there, you'll be asked whether you want coverage or benefits. If you've recently activated your health insurance, or are curious as to when your plan expires or begins, you want coverage. If you want detailed information regarding your specific plan, you want benefits. 

Benefits will give you your copay's, out-of-pockets, deductibles, etc.  Many systems are automated now-a-day, so ask to "speak to a representative" and the system should transfer you to an actual person who can help. 

Copay, Deductibles, and Out-of-Pockets

Copay: A flat-rate payment you make each time for a specific medical service - not everyone has one in their plan. 
Example: Paying $25 dollars each time you go in to see your doctor for updated prescriptions, or each time you go in for physical therapy. It can range from $10 for an office visit to in the hundreds for things like an emergency room visit. It is due every time at the start of your appointment. May or may not be applicable to your deductible, but is always applicable to your out-of-pocket maximum.

Deductible: A defined amount of money the policyholder must meet in order to receive insurance coverage AT ALL. 
Example: This is usually a number somewhere in the middle, ranging anywhere from $100 to $5-6,000. You will need to meet your deductible in it's entirety before any insurance coverage will kick in. 

Out-of-pocket Maximum: Defined amount of money the policyholder must meet in order to receive full coverage by their insurance (the insurance company pays 100% of the medical bill). 
Example: This is usually a much higher number, anywhere from $500 to $10,000. Your insurance coverage while you work to meet your out-of-pocket maximum can range anywhere from 60/40 to 100% coverage. 

These three will re-start each year, either associated with the calendar year, or the policy year. The policy year is simply a year from which your coverage began. They are applicable to all types of coverage under that type-umbrella, so all types of medical or all types of dental; meaning, your deductible for your medical coverage is different than your deductible for your dental coverage. 

IS YOUR INSURANCE IN - NETWORK?

Rolling off that post last Thursday regarding the differences between copays, deductibles, and co-insurance, we go to the next aspect of it that affects certain patients at Champion Performance and Physical Therapy directly: whether we are in-network with your insurance, or out.

In-Network essentially means this clinic (or any doctor's office) has signed a contract with your insurance.  We abide by their rules as far as scheduling and charging for your visit, and they allow patients to utilize their in-network benefit coverage to see us here. Whether or not we are in-network with your insurance is generally determined by whether or not we have the demand for in-network benefits.  If we have enough patients with a certain insurance we are out-of-network with, we'll look into become a so-called "member" of that insurance, or becoming an in-network clinic. 

The reason it's appealing to use in-network is because it is almost always cheaper for the consumer, or in this case, the patient. The deductible for in-network plans are lower, as are out-of-pocket maximums, etc.; both for individual and family plans.

Insurances allow patients to utilize their out-of-network coverage as freely as they do their in-network coverage, but because the deductibles/co-insurances/out-of-pocket maximums are so much higher, it makes more sense for the patients to attempt to locate an in-network provider, instead.

Out-of-Network is more likely to occur with some insurances that may be private, less common, or small, compared to the big-name, widely-renown groups such as Blue Cross or United HealthCare.  A part of membership for providers may require either extensive paperwork, or monthly fees from the provider; which can also lead them to remain out-of-network, despite the demand from their patient demographics. 

How do you know if you have in-network or out-of-network coverage, at all?

You'll call that same customer service line on your insurance card. Many plans include out-of-network coverage, but some do not. Those plans will have lower premiums, and the deductibles can vary from far below average to way above average. 

Keep in mind: having only out-of-network coverage at a specific clinic does not necessarily mean they do not accept your insurance. 

Some clinics, including us, accept certain forms of out-of-network coverage. While we can't speak for other clinics, we, here at Champion Performance and Physical Therapy, will do what's called "match your in-network benefits." 

What this essentially means is, while we are not in-network with your insurance, we will do you a favor and go based on your in-network benefits, instead of your out-of-network.

For example: your in-network deductible is $1000, but your out-of-network deductible is $2000. We will abide by your $1000 deductible, as opposed to the latter. The same goes for co-insurance and co-pay. 

Why do we do this, you ask? 

In some cases, it may be a smarter business decision in the long run with certain plans or insurances. We may not have the demand for that insurance to become in-network, or the plan itself would not benefit the patient or the provider as much as it would in-network. However, our belief in the relief physical therapy here at Champion provides, means we want to open our doors to as many individuals as possible - basically we do it because we don't want your insurance to get in the way of a healthy rehabilitation with us. We urge you to contact our clinic location at 913.291.2290 - and we'll do our best to walk you through this process as you start therapy with us, as well as ensure that you're getting the best "bang for your buck!"

Please note: we accept almost all plans from most major insurances, including: Aetna, Blue Cross Blue Shield, Medicare, UnitedHealthCare, Humana, and more.  Call for more information regarding whether or not we accept your insurance, or specific plan.