Understanding Your In-Network Coverage

Billing Partner

KEGE Center for ADHD works with a billing partner called Alma to manage medical insurance billing. Alma specializes in handling insurance billing matters, including copayments and coinsurance, on our behalf. They are a trusted partner and handle insurance plans copayment, and or coinsurance.

Understanding your insurance benefits and what it covers can be confusing. This simple resource defines key terms and outlines how your insurance works. 

Cost estimator 

When you want to use your insurance to see a provider, the provider conducts an eligibility check. An eligibility check confirms A) that your coverage is active, B) that your insurance benefits cover the services they provide, and C) how much the insurance company estimates your service will cost (your payment responsibility). 

If at any point your insurance plan changes, a new eligibility check is needed. Please notify your provider and they can update your insurance details or share a link with you to update them yourself! From there our team will run a new eligibility check to ensure we have the correct coverage status and payment responsibility on file for your new plan.

You can get a cost estimate for in-network mental healthcare using Alma’s cost estimator tool if you are insured by Aetna, Cigna, Oxford or UnitedHealthcare (UHC). Learn more about this tool, or try it yourself here.

Payment Responsibility

Insurance companies contract with providers to provide services to patients covered by their insurance plans. When they do, the providers (“in-network providers”) agree to accept specific rates for different services (the “contracted rate”). When you receive care from a provider, you will pay a portion of the contracted rate and the insurance company pays the rest. We refer to this as your payment responsibility. Depending on your insurance plan, your payment responsibility can range from $0 up to the full cost of the contracted rate. 

Your payment responsibility usually comes in two plans:

A copay: You pay a certain amount for each session regardless of the contracted rate and your insurance company covers the rest.

A coinsurance, after meeting your deductible: You pay a specified percent of your provider’s contracted rate and your insurance plan picks up the rest. Typically, plans that involve a coinsurance require you to pay the full contracted rate until you meet your deductible, after which your insurance will cover a percentage of all costs. 

What is a deductible and out-of-pocket maximum?

A deductible is the set amount you pay each year for your healthcare before your plan covers any of your healthcare costs. For example, if you have a 10 percent coinsurance subject to a $1,000 deductible, you have to spend $1,000 on healthcare before you’re eligible to pay for only 10 percent of visit costs. 

An out-of-pocket maximum is a limit meant to protect you and is set by your insurance plan. This limit is the maximum dollar amount that you could potentially spend on healthcare in a policy year. Once you reach your out-of-pocket maximum, your health insurance plan covers 100 percent of all covered services for the rest of the year. Any money you spend on deductibles, copays, and coinsurance counts toward your out-of-pocket maximum. However, premiums don't count and neither does anything you spend on services that your plan doesn't cover.

Two examples:

Example 1: Imagine your insurance benefits include access to outpatient behavioral health services at a copay of $20 per session until you meet your deductible, at which point care is $0 per session. Your deductible is $1,000. Let’s also imagine that the contracted rate is $200 per visit.

Each visit will cost $20 until the total amount you’ve spent on medical care, processed through your insurance, reaches $1,000 (this can be for therapy or any other medical services for which you use your insurance). After five (5) visits, you’ve paid $100 ($20 x 5 visits). That means you’ve paid $100 toward your $1,000 deductible so far, and you have to spend an additional $900 dollars before your insurance plan drops your cost to $0 per session.

Example 2: Imagine your insurance benefits include access to outpatient behavioral health services, but you have to pay the full cost of each visit until you meet your deductible, at which point care is $0 per session. Your deductible is $2,000. Let’s also imagine that the contracted rate is $200 per visit.

Each visit will cost $200 until the total amount you’ve spent on medical care, processed through your insurance, reaches $2,000. After five (5) visits, you’ve paid $1000 ($200 x 5 visits). That means you’ve paid $100 toward your $2,000 deductible so far, and you have to spend an additional $1000 before your insurance plan drops your cost to $0 per visit.

Your provider runs monthly eligibility checks for you based on the appointments your provider has scheduled for you in their calendar. These checks will reflect changes in your payment responsibility if you reach your deductible and shift over to a copay or coinsurance.

If you are within $200 of meeting your deductible, we will let you know via email and begin invoicing you as if your deductible has already been met. This is to avoid over-charging you if the full cost of your visit is higher than your deductible amount. If we discover that you owe more than you were originally billed, you will receive an updated invoice with the outstanding balance.

Billing

After each session, we will submit your claim to your insurance company and you’ll receive an invoice for care. The invoice should reflect the cost estimated during your eligibility check. If you owe a copay, you’ll be invoiced for that copay.

Sometimes the estimate from the eligibility check doesn’t match your invoice. This can be confusing, so it’s worth explaining why and how this happens.

After each visit, your provider will submit a claim to the insurance company. When the insurance company receives the claim, it looks at your benefits, what you’ve already spent on care, and decides how much money to pay the provider for their visit with you.

Any difference between your provider’s contracted rate and the amount your insurance company agrees to pay will become the patient’s payment responsibility, or the dollar amount you will owe for the visit.

While this amount should match the estimate given to you during your eligibility check, there are a few reasons for possible discrepancies:

You meet your deductible. If you receive other medical care and have met your deductible in the period between your eligibility check and the claim being submitted, your payment responsibility might change.

The services provided are different from those checked at eligibility. For example, your provider may check eligibility for a 45-minute visit, but you and the provider extend to 60 minutes. Because a 60-minute session is considered a different service than a 45-minute session, and since each service has a different contracted rate, your resulting payment responsibility might change.

Your benefits change. During COVID-19, many insurance companies and employers added a temporary benefit to some health plans, waiving the payment responsibility for virtual mental health visits. Eligibility for these waivers varies by policy and your insurance company. Some insurance companies have been processing the waiver inconsistently, meaning some visit claims are processed with a $0 payment responsibility and others are processing with normal payment responsibilities. As a result, you’ll receive an invoice for each claim returned to us showing that you owe a payment responsibility for your appointment, and you will not receive an invoice if your claim shows that you owe $0.