“What Does My Insurance Mean?”

So, you have concluded that you need therapy services but are not sure what costs will be your responsibility. You will hear words like “Deductible”, “Coinsurance” and “Authorizations” but what does all this really mean? We are here to help. We have compiled a list of the most commonly asked about insurance terms, and their definitions to help you better understand how they relate to you, your therapy services, and just what you can expect to contribute out-of-pocket.

  • Premium: A premium is a set amount that you pay per month for your insurance. If you have commercial insurance that is through your employer this premium will typically be taken out of each paycheck.  
  • Primary Insurance: Primary insurance is the first thing to receive anything from a medical office. Everything has to go through the primary insurance first.
  • Secondary Insurance: Some may have what is called secondary insurance and it is just another insurance policy that can sometimes pick up what the primary insurance left to patient responsibility. 
  • Deductible: A deductible is a set amount that you will have to pay before your insurance policy will start paying. This means, if you have a deductible of $1,000.00 you will have to pay that $1,000.00 before your insurance will start to chip in. If you went to the doctor’s office and they charged $100.00 having a deductible would mean you would be responsible for the full $100.00 and insurance would not pay anything towards it. Now, having a deductible does not mean that insurance does not cover this. The insurance company is still covering and allowing the charges, they are just leaving the balance to patient responsibility. 
  • Copay: A fixed amount that you pay at every appointment (typically after you have met your deductible). A copay is typically a smaller amount for doctor’s visits, (like $20.00) that is due at the time of service. After you have paid the copay, your insurance policy will cover the rest of the balance. Say you went to see your doctor, no matter what the doctor’s office bills, if it’s $20.00 or $100.00 you would only be responsible for that copay. So, if your copay was $20.00 and the doctor’s office only billed $20.00 worth of charges, the insurance would not pay anything. The insurance would leave the balance to patient responsibility. If the doctor’s office charged $100.00, you would only be responsible for that $20.00 and the insurance would pay for the remaining balance of $80.00. If you had a $20.00 copay but the doctor’s office charged less than $20.00 for what was done that day, you would only be responsible for what the doctors charged.
  • Coinsurance: A coinsurance is a percentage of the charges that is left to your responsibility (typically around 10%-30%). After you have paid that percentage, the insurance policy will pay the remaining balance. If you went to the doctor’s office and they charged $100.00 and say your coinsurance was 10% you as the patient would be responsible for $10.00 and the insurance company would pay the remaining $90.00. 
  • Out-of-Pocket: An out-of-pocket is a set amount that you will have to pay before your insurance policy pays at 100%. This amount is comprised of your copays and coinsurance and is typically more than your deductible. So, if you have a copay or a certain percentage that you must pay at each visit, all these funds will be going towards your out-of-pocket.  
  • Visit Limit: Some insurance policies will only let you have a set number of visits for therapy services. This number is the number of visits that they are willing to cover.  It is not uncommon in the therapy world for some policies to combine Occupational and Physical Therapy visits. 
  • Authorizations: Authorizations are requests that the treating provider must submit to the insurance company to get permission to treat the patient. Typically, these are submitted after the therapist has performed an evaluation and a Plan of Care is written and able to be sent. The insurance company will typically approve around a month at a time because that is when a re-evaluation is needed and an updated Plan of Care is sent. The insurance will have a therapist that is working for them review the notes and make sure that the therapy is still medically necessary.  
  • Health Savings Account (HSA): An HSA is something that is offered by the insurance company for you to personally set aside money for medical expenses. Think of it as a bank account that can only be used to pay for doctor’s appointments or medication at the pharmacy. A health savings account is also the same as a flex spending account. 

If after reading all of this, you still have questions, learn more about how to get started and what to expect when you book an appointment with Niagara Therapy, LLC. If you need further assistance, please contact the office and somebody here will be glad to help you! 



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