A Quick Guide to Health Insurance

Unfortunately, figuring out what your health insurance plan covers can be confusing. For many of our patients this is one of the most stressful, and annoying, steps in finding a doctor or physical therapist. What does in or out of network actually mean? What is the difference between co-pay and co-insurance? How does the deductible affect what I pay?

A quick note: when using health insurance, the cost of services is highly variable and dependent on the patient's unique plan. In order to get the specifics, we must verify your insurance benefits.

Some simplified Terminology:

Premium: The monthly payment you, or your company, pay to be covered by a health insurance plan.

Deductible: The amount a patient is responsible for paying BEFORE the insurance company will contribute to the cost. Deductibles reset each year.

e.g. If you have a $500 deductible, you will be responsible for paying the first $500 worth of services. Once you have spent $500, you will then be accountable or your usual co-pay or co-insurance.

Co-pay: A fixed fee the patient is responsible for paying each visit.

e.g., if your co-pay is $20, you will be responsible for paying $20 for each visit

Co-insurance: A fee equal to a percentage of the total cost for each service. The percentage is determined by your insurance plan.

e.g. A co-insurance of 20% for a $100 service will cost the patient $20

Out of Pocket Max: The maximum amount a patient is responsible for paying during an insurance year. Your insurance premium does not contribute to this number.

e.g., If your out of pocket max is $2,000.00 and you have paid this amount by reaching your deductible and paying co-pays/co-insurances, the insurance company will pay all authorized expenses in full for the remainder of the plan.

In-Network: Going to an in-network provider means you are going to a provider who has a contract with your insurance plan. Your standard deductible and co-pay, or co-insurance rate will apply. In-network providers are not necessarily less expensive than out of network providers.

Out of Network: An out of network provider is not under contract with your insurance company. Therefore, you will pay an agreed upon rate with this provider and your insurance company will cover a percentage of that rate. Out of network providers are not necessarily more expensive than in-network.

At Kauno, we do our best to make payment as transparent and straightforward as possible. Before your first appointment, we will gladly verify your insurance benefits and explain precisely what you will be responsible for during the duration of your care. We are also happy to answer any insurance related questions in more detail at anytime.

-Brian King PT, DPT, CSCS