Insurance 101: A Simple Guide to your insurance plan

The purpose of this post is to help readers understand how their health insurance works. Many people do not understand what they will end up paying in out-of-pocket expenses for healthcare services. Most people think they will just pay a $20 copay per visit because they have health insurance, but not all plans are the same.

It’s very important to understand your health plan and how it works.

FYI - You DO NOT need a referral to be seen at BYLT Physical Therapy

I’ll start by defining a few terms that are the most important to know for the insurance you have or when you are trying to pick a health plan:

• Copay/Coinsurance - the amount you owe for an appointment. A copay is a fixed amount (ex., $30), where coinsurance is a percentage (ex., 20%).

• Deductible - this is typically what you will pay “out-of-pocket” before your insurance ever pays anything. There are some plans where certain types of visits do not apply to this and you simply pay a copay regardless.

• Out-of-Pocket Maximum - Once you have paid this amount “out-of-pocket”, your health plan will cover 100% of your medical and healthcare expenses.

  • Most plans do have limits on the number of visits you are allowed for certain visits (such as PT). Once you are out of allowed visits, your insurance plan requires you to pay “out-of-pocket” for those visits regardless of how much you have spent for the year.

• Monthly Premium - Your monthly cost to be on your insurance plan.

It’s important to know all of these factors before receiving medical care, to understand how much you will have to pay, and understand how much your insurance will pay. Also, it’s helpful to understand these factors when choosing the right health plan for you. Some plans have lower monthly premiums, but you will usually spend more when you actually go see a provider. Plans with higher premiums will likely have lower out-of-pocket costs.

Let’s go through a few scenarios of how much you will pay on different plans - We will use Physical Therapy as the example and keep the price insurance will allow at $100 for simplicity:

Person A — Copay: 20% | Deductible: $2500 | Out-of-pocket Max: $5000 | Premium: $500/month

• This person has not met their deductible yet, they might not for a while unless they had a surgery, MRI, or other health event.

  • Out-of-Pocket Cost per visit: $100 until the deductible is met

Person B — Copay: $25 | Deductible: $500 | Out-of-pocket Max: $2000 | Premium: $1000/month | PT visits do not apply to deductible

• This person has not met their deductible yet, but with this plan they can have PT visits for just their copay, no matter what. Plans like this will likely have a higher premium, so monthly costs are higher. Plans like these are very good and are usually offered by bigger employers.

  • Out-of-Pocket Cost per visit: $25

Person C — Copay: 15% | Deductible: $250 | Out-of-pocket Max: $2000 | Premium: $800/month | Person has met their deductible for the year

• This person has met the deductible of $250. They will pay the $250 out-of-pocket for any medical bills prior to insurance paying anything, but once they do, insurance will cover 85% of healthcare costs. Since they have met it, they only pay the 15%.

  • Out-of-Pocket Cost per visit: $15

These are all for In-network providers. For out-of-network providers, out-of-pocket costs are usually more, you have higher deductibles and out-of-pocket maximums when a provider is out-of-network (when a provider is not set-up or contracted with that insurance).

This is a very brief and simple overview of insurance and how to determine what your out-of-pocket costs for healthcare will be. What we discussed are the main things to consider, but it is always important to understand your health plan to know what is covered and what is not to avoid unexpected medical costs.

At BYLT PT, we want to provide the highest value care possible, while not breaking the bank of our clients. Because of that, we are contracted with certain insurances. If you would like to know if we are contracted with your insurance, please contact us through our contact form, by phone, or check out a list here.