BCC started accepting insurance in an effort to be both sustainable and accessible. Prior to accepting insurance, we used a sliding scale model, but we found the sliding scale model either didn’t go low enough to be truly accessible, or it didn’t allow us to pay our clinicians a living wage. Many folks struggle to understand their insurance benefits, so we have collected a few useful tips and definitions here.
Medical Necessity: for insurance to pay for therapy, it needs to meet criteria for medical necessity. There are three parts to medical necessity: a diagnosis, (usually documented using the ICD codes) impairment (generally, how the issue impacts your daily functioning, including things like sleep disturbance, occupational, academic, or interpersonal struggles, and changes in appetite) and interventions that are in alignment with best medical practices. Insurance doesn’t cover services it considers to be elective or for your own convenience or preferences. While some insurance companies still cover relationship issues, many require a diagnosis that would be helped by supportive relationships, such as substance use disorder or major depression.
Deductible: A deductible is the amount you are expected to pay before insurance starts paying. These costs are lowered to the amount we have contracted with insurance companies– so even if you won’t meet your deductible, an in-network therapist will cost less. Once you’ve determined that your therapist is in-network for your insurance company, and that you’ve established medical necessity, your insurance will kick in. If you have a low-deductible plan, you may only have a co-pay of $15-40 from the beginning. Other plans require you to meet your deductible before the insurance pays anything. If you have an HSA debit card, it is more likely that you have a deductible that needs to be met. We will file your insurance, then the insurance company will adjust the price of your therapy to match our contract, and then we will charge your HSA or credit card for the session. This may happen anywhere from a couple days to 3 weeks after your session.
Co-pay/Co-insurance: A co-pay is something that you pay along with the insurance company for each appointment. On your insurance card it will say something like, “office visits” and then an amount. Co-insurance is the percentage of the fee that you pay even after your deductible is met– usually something around 20 or 30%. We bill your credit card this amount once the insurance adjusts the price according to our contract.
Contractual Obligation: This amount will show up on your explanation of benefits as the amount we have contracted with your insurance company for a provided service. It is almost always lower than our billed price. It is against contract for an in-network medical practice to “balance bill,” or charge you the amount between what the insurance company pays/allows and what we charge.
Explanation of Benefits EOB: An explanation of benefits is a letter you get from your insurance company (we also get a copy) that outlines what we filed (for example, 90837 means we did 53 or more minutes of individual therapy) and what the insurance company paid. It usually says “Not a bill” at the top. It will say what you owe, what they paid, and how they adjusted the amount.
Out of pocket max: This is the amount at which your insurance plan kicks in for 100% of charges that are in-network. Most plans have a separate in-network max and an out-of-network max. While it can be a relief to reach your out-of-pocket max, services still need to be medically necessary and using best practices to be covered by insurance.