I call insurance companies almost every day, and I have to admit that it is confusing. Seventy seven percent of Americans have insurance coverage either through the state, their employers, or self-funded avenues, but few people fully understand their policy. I only understand insurance as it applies to the nCenter, and I am not qualified to give advice on health care coverage. However, after a year of calling insurance companies to have our clients’ plans explained in detail, I have a fairly good understanding of the basics.
First, there are three main ways to acquire insurance. Low income individuals or families, and senior or disabled citizens can receive insurance through government administered policies such as Medicaid or Medicare. If Medicaid determines that a client is eligible for a copay, the copay will range from $4 to a 10% coinsurance. Neurofeedback, brain maps, youth nutritional counseling, and psychological testing are also covered under Medicaid. The nCenter is proud to be one of the few counseling offices in the Gallatin Valley that accepts Medicaid and Medicare. For citizens who do not meet the requirements to receive Medicaid or Medicare, many employers offer insurance coverage as a benefit. Others chose to purchase insurance privately and fund their own policies. From company to company and policy to policy, insurance coverage can vary greatly.
In order to get an understanding of the language of insurance, like CPT codes, in and out of network providers, copays, coinsurances, deductibles, and out of pocket maximums I’ll tell you about my hypotheitcal friend Nancy Center, or N. Center. Nancy is insured under Theory Coverage. Her specific plan with Theory has a $1,000 deductible, a $5,000 out of pocket max, $35 copays for office visits, and a 25%/75% coinsurance split for lab and diagnostic procedures. Let’s say that our office is in-network with Theory Coverage.
We’ll start with CPT codes. Basically, CPT codes are universal identifiers for certain behavioral and medical procedures. Every procedure whether at the nCenter, the hospital, or some other place of service is linked to a CPT code that indicates what it is. For example, all counselors bill a client’s insurance company under the CPT code 90837 for a 60 minute counseling session. The insurance company either covers or does not cover that code. The code also has to be linked to a diagnostic code that pertains to the procedure. Of course, it doesn’t end there, another caveat is whether or not the counselor is in or out of network with the insurance company. In network means the counselor has a contract with the insurance company, out of network means the counselor does not. Nancy’s insurance covers all the services offered through the nCenter and her diagnosis deems them medically necessary, and the counselor is in network with Theory Coverage.
Ok, let’s say we bill the insurance company for a coverable CPT code with a diagnostic code that indicates medical necessity under an in network provider. Nancy should all be covered, right? Unfortunately…. not necessarily. Many CPT codes fall under the policy’s deductible. The deductible is a dollar amount that is determined when the policy is bought. This is the amount that the insured is contracted with their insurance company to pay before insurance starts coverage for services. Nancy’s policy has a $1,000 deductible, this means $1,000 worth of covered medical procedures must be billed and paid for out of her pocket before the insurance benefits kick in. I have seen deductible ranging from $0 to $10,000. Accumulations towards the deductible reset every year, meaning most start over in January or whenever the plan’s benefit year begins. Thankfully, many insurance policies waive the deductible for mental health coverage so that in some cases the deductible does not need to be met before the company will start paying for counseling sessions and only assigning the insured a copay.
Alright, now Nancy has met her deductible and the benefits offered by Theory Coverage will begin to be applied to future visits. Counseling at the nCenter is considered an office visit. Since Nancy’s plan has a $35 copay for office visits, she will now only be responsible for $35 of the cost of service, and her insurance will cover the rest. Copays, like deductibles vary depending on the policy. Nancy also would like to get a qEEG brain map. Brain maps are billed under lab benefits since they are a diagnostic tool. Her policy has a 25%/75% coinsurance split for lab benefits. This means that her insurance will pay for 75% of the procedure’s cost and she will be responsible for 25%.
Finally, we’ll go over out of pocket maximums. This is the dollar amount Nancy must pay before her insurance will cover her fully. Most policies include the accumulation of meeting the deductible and paying any coinsurances and copays in reaching the out of pocket. Like the deductible this amount resets every year. Nancy has a $5,000 out of pocket. Once the total she has paid in billable CPT codes towards her deductible and paying associated copays and coinsurances reaches $5,000 her policy will drop the copays and coinsurances and cover 100% of Nancy’s costs (as long as they are covered CPT codes associated with an appropriate diagnostic code through an in network provider).
There are a lot of hoops to jump through in order for insurance to actually pay for things. Here’s some reassurance that being insuranced is beneficial. According to a study published in the American Journal of Public Health, because those of us with insurance are more likely to seek medical care, we are 40% less likely to die every month. I’m sold. And, thankfully as of 2014, most insurance plans require that policies cover CPT codes related to mental health care. The number of individuals who are insured has increased over recent years and experts are hopeful this will mitigate health costs in the long term.
At the nCenter, we know that insurance is confusing and intimidating. Because of this, all our clients start their care at the nCenter with a complimentary consultation. Our front desk staff then calls our potential client’s insurance company and learns exactly what their plan entails, what is and isn’t covered and what has been met so far. Though we cannot guarantee coverage until we receive the results of submitted claims, this gives us a good indication of how much services will cost our clients. We then discuss costs and coverage with our clients so they can consider any financial obligations they might incur.
To schedule a complimentary consultation with the nCenter, give us a call at 406-599-2492—and don’t forget to bring your insurance card!