Insurance benefits can be very confusing for many people. Here are some definitions to get you started. You can also contact the member services number on the back of your insurance card for support.
Benefit Plan means a certificate of coverage, summary plan description or other document or agreement which specifies the health care services to be provided or reimbursed for the benefit of a Participant.
PPO plans are generally more affordable and require you to see a provider in network. An individual with an HMO plan may see a [provider out of network and ask a provider for a super bill, a special form of receipt, that they can submit to their insurance for reimbursement. Reimbursement rates may differ per insurance and you can find out what your insurance will reimburse for services by contacting member services.
Here is a script for contacting your insurance regarding an out of network provider:
“Hello, I’ve found a therapist that is out of network, my understanding is that with my PPO insurance I can see an out of network therapist. I need to ask a few questions before I get started:
- Please confirm I can see this therapist and do I have to meet a deductible before I get reimbursement? If so, what is my current deductible.
- My therapist says I have ____ diagnosis, is this reimbursable and if so what will I get reimbursed for _____ diagnosis? (Often times insurance may need to know what the diagnosis is in order to tell you if you will get reimbursed. While a therapist can not give this until sessions have been completed, most people who see me are dealing with one of the following diagnoses: Major Depressive Disorder, Adjustment Disorder, Generalized Anxiety Disorder, or some Substance Use related disorder.)
- Does my therapist need to submit anything to you in order for me to receive reimbursement? (If so get an email or mailing address and list of what they need, i.e. copy of professional license etc.)
- How do I submit superbills for reimbursement and does it matter how frequently I submit them? (i.e. can you as the client submit monthly or bimonthly instead of after each session?)
For more on HMO vs PPO health Plans, read this article.
Coinsurance means a payment that is the financial responsibility of the Participant under a Benefit Plan for Covered Services that is calculated as a percentage of the contracted reimbursement rate for such services or, if reimbursement is on a basis other than a fee-for-service amount, as a percentage of an Insurance determined fee schedule or as an Insurance. determined percentage of actual charges.
Copayment means a payment that is the financial responsibility of the Participant under a Benefit Plan for Covered Services that is calculated as a fixed dollar amount. If you are in New Mexico, you should not be paying any copayment. Read more here and contact your insurance with any issues.
Covered Services means those health care services for which a Participant is entitled to receive coverage under the terms and conditions of the Participant’s Benefit Plan.
Deductible means a payment for Covered Services calculated as a fixed dollar amount that is the financial responsibility of the Participant under a Benefit Plan prior to qualifying for reimbursement for subsequent health care costs under the terms of a Benefit Plan.
Medically Necessary/Medical Necessity means services and supplies that satisfy the Medical Necessity requirements under the applicable Benefit Plan. No service is a Covered Service unless it is Medically Necessary. In order to show this, your therapist is required to provide you and your insurance with a mental health diagnosis from the DSM.
Participant means any individual, or eligible dependent of such individual, whether referred to as “Insured,” “Subscriber,” “Member,” “Participant,” “Enrollee,” “Dependent” or similar designation, who is eligible and enrolled to receive Covered Services, or who is a continuing care patient as defined by applicable federal law.
Participating Provider means a hospital, program, physician or group of physicians or any other health care practitioner or entity that has a direct or indirect contractual arrangement with Insurance to provide Covered Services with regard to the Benefit Plan covering the Participant.
