What is a deductible?


A deductible is a set amount of out of pocket expenses you need to meet, before your insurance will contribute towards your expenses. For example, if you have a $1,000 deductible, and 20% Coinsurance for chiropractic, you would need to pay out of pocket for $1,000 of medical expenses, after which your insurance would then pay for 80% of your chiropractic care, and you would be responsible for the other 20%. Prior to your deductible being met, you would be responsible for 100% of the visit cost. Deductibles usually cross accumulate, and are based on all of your medical expenses, not just once service type.

What is co-Insurance?


Coinsurance is the percentage of your care you are responsible for paying after your deductible has been met. For example, if you had an 80/20 plan, you would be responsible for 20% of your visit cost, and your insurance would pay the other 80%. The cost of your percentage is procedure based, so there may be fluctuation in the cost based on what you have done each appointment.


What is a copay?


A copay is a set amount you are responsible for for your appointment, regardless of what procedures you have completed in your appointment. For example, if you have $30 copay, you would pay $30 of your visit cost every appointment, and your insurance would pick up the remainder. Some insurance plans will also implement a separate copay for exams, meaning that exam days will be slightly higher than your regular copays.


What does “maximum out of pocket” mean? What happens when I meet it?


Your max out of pocket amount is an amount set by your insurance plan, as a “cap” for how much you can spend out of pocket on your healthcare. This is the maximum amount you will have to contribute. After the max out of pocket has been met, your insurance will pay for 100% of your visit cost, up to your visit limit. For example, if your max out of pocket is $3,500, and you incur $4,000 in medical expenses, you would only be responsible up to the $3,500, and your insurance would cover all remaining expenses, provided that they are approved.


Myth: I have to wait for my insurance to process my visit before I can pay my co-insurance.


We verify your insurance before seeing you, and know what your visit cost will be based on your benefits before the claims process. You can pay at time of service, and the cost should not change after it is processed by the insurance. It will also apply to your out of pocket cost the same as if you paid after processing.


When should I give you updated insurance information?


As soon as possible! Insurance has timely filing deadlines, so the sooner we get your insurance information updated, the better chances we have of getting your visits approved.


I got a letter from my insurance saying you requested an appeal. What does that mean?


If an insurance company does not pay what we were told they would pay, we send in an appeal. We base your appointment cost on what they quote us for benefits, and if they do not process your visits the same way as they quoted us, we appeal their claims. We always try to work with the insurance company to make sure you’re getting the appropriate benefits for your care. Don’t worry, if there is any action that you need to take, or any changes to your benefits, we’ll be sure to let you know!


What does In or Out of Network mean?


In network means that we have contract pricing with your insurance, and your insurance offers chiropractic benefits at a preferred rate. Out of Network means we do not contract with them, and your insurance may not offer chiropractic benefits, or will offer them at a higher rate.


My insurance has two rates for In-Network insurance. What does that mean?


Some insurances now offer two tiers under In Network as well, usually referred to as Preferred In Network and Standard In Network. This was the insurance way of trying to offer more coverage in their in-network providers. Both provider lists are in network and contract with your insurance, however your preferred provider list will often have better insurance benefits with lower premiums, or copays instead of coinsurance. Check your insurance website or call your insurance customer service line for more information about these benefits.

 – Megan