The end of the year is coming up quickly. This means that it’s almost time to choose insurance plans for next year. It can be difficult to understand exactly what you’re signing up for. EPO-HMO-HSA, or 80/20 coinsurance; how do you read through the alphabet soup and ratios? Here is a quick break down of the most common terms to help you with understanding insurance plans.
Parts of a Plan
Deductible and Coinsurance
If your mental health benefits have a deductible, this is the amount of money you have to pay before your insurance will cover a portion of the session cost. So if you have a $2000 deductible, and the session cost is $200, you would pay for 10 sessions before your insurance would cover a portion of the fee.
Once that deductible is met, your coinsurance amount kicks in. Insurances typically break this down into a percentage of the fee that you pay vs them, so you may have a 20% coinsurance, which means your insurance plan covers 80% of the session cost, and you cover 20%. So again, if the session fee is $200, insurance would cover $160 and you would be responsible for $40 per session.
Out of Pocket Maximum
You typically will also have an out of pocket maximum amount that is higher than your deductible. This is the maximum amount of money you can spend before your insurance plan begins to cover 100% of your session costs. So if your OOP Max is $3000, you would spend $2000 with your deductible, then $1000 in coinsurance payments before your insurance provider would cover 100% of costs.
Copay
Some plans either do not have a deductible. Instead you are assigned a fixed copay amount per session. You have the same copay for all types of therapy sessions. The only exception to this would be if you hit an out of pocket maximum, and insurance would then cover all costs for the remainder of the year. You often see copays listed on your insurance card.
Out of Network Benefits
If your insurance plan is not in network, you might have out of network benefits. These are typically a separate deductible and coinsurance offered by your insurance provider. Out of network deductibles are often higher to encourage you to see providers who are in network. Some plans do count money spent on out of network costs towards the Out of Pocket Maximum, and others do not.
Types of Plans
EAP: Employee Assistance Program (EAP)
This is an insurance benefit where the client’s job pays the full cost for a certain number of sessions. Once all of the sessions are used, you can either request an additional EAP, or switch to using your regular benefits.
PPO: Preferred Provider Organization
PPO plans offer a network of ‘in network’ healthcare providers that can be in multiple hospitals or organizations. Typically PPO plans don’t require any type of doctor’s referral and are the most flexible.
HMO: Health Maintenance Organization
A type of insurance plan that is focused on a smaller group of ‘in network’ providers. (Typically all existing within a single hospital system.) HMOs mean that most other services require referrals from your primary doctor.
EPO: Exclusive Provider Organization
Similarly to an HMO, there is a smaller group of ‘in network’ providers you can choose from, however they may be across multiple hospital systems. These plans typically don’t require referrals from your primary care physician (PCP) and resemble a PPO plan.
POS: Point of Service
These plans are similar to an HMO, but only have you select one doctor as your ‘in network’ provider. All other services are out of network, and you might need a referral from your doctor to see specialists.
HSA, FSA, and HRA
Any PPO or HMO plan could also have one of the following:
Health Savings Account- Money is added by you to use as you need. This type of account is owned by you and the funds can transfer from one plan to another. (Both by rolling over each year, or from one company to another since you fund and control the money.) These are more typical with high deductible insurance plans.
Flex Spending Account- Can be linked to high or low/no deductible insurance plans. These accounts usually have money added by you, but some employers might supplement funds. Flex spending typically does not roll over year to year. Use it or lose it!
Health Reimbursement Account- Where your employer deposits funds into an account to supplement your medical costs. Your employer also maintains an approved list of which medical and dental expenses are eligible for reimbursements.
What Do I Choose?
Only you can know what the best plan will be for yourself or your family. A PPO may offer you more flexibility, but an HMO may cost less. Don’t forget to contact the benefits team when you’re choosing a new plan. They or your provider can tell you what plans are accepted and help your decision. Questions about the insurances Urban Wellness takes? Check our our New Client Info Page for details on insurance and to check your benefits with our Mentaya App at the bottom of the page.
0 Comments