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Can you help me figure out my health insurance coverage?

Can you help me figure out my health insurance coverage?

Common blue butterfly

Generally, health insurance plans come in 3 types: HMO, PPO, and EPO. Most of the time this is explicitly stated on your insurance card. You can always call your insurance company to find out, usually through a number listed on the back of the card, or call the HR person at the business which provides the insurance.

Professionals on your insurance panel are otherwise known as in-network. Professionals that are not on your insurance panel are otherwise known as out-of-network.

  • PPO insurances have an in-network arm and an out-of-network arm.
  • HMO insurances do not pay toward out-of-network visits; they only have the in-network arm.
  • EPO is a hybrid network that does not pay towards out-of-network visits.
  • Kaiser is a type of HMO insurance. It does not pay towards any professional who is not a Kaiser provider except under special circumstances, like Emergency Room visits; also, Kaiser will generally only fill prescriptions from Kaiser providers.
  • Medicare is complicated and it all depends.
  • Other Medical Funding, while not insurance, is another way to pay for medical expenses.

PPO Insurance

A PPO encourages you to use in-network clinicians (which I am not) and this usually costs you the least money out-of-pocket. A PPO also has an out-of-network arm, which allows you to go to any provider. You need to look into this very carefully since many insurances have a separate and higher deductible associated with the out-of-network arm. In addition, when the insurance says they pay 50% of out-of-network costs, they mean 50% of what they say is the maximum amount allowed for a specific code, usually less than many providers charge. For example, if you pay me $250 for a session, but your PPO only allows a maximum of $200, they will pay 50% of the $200, which is $100. You will be responsible for the remaining $150.

HMO Insurance

If you have an HMO, that means that your insurance will only pay money towards your health care if you use an in-network clinician. This means they will not pay for my services because they will not pay for any treatment outside of their network; unless you have negotiated a special contract that they and the clinician agree to (this is a rare situation).

EPO Insurance

EPO insurance is a hybrid of PPO and HMO insurance. The PPO aspect means that you can usually access any specialty without a referral from your primary care physician. This allows you more freedom to choose the treatment that you want, rather than having to get a referral from the primary care doctor for every step of the plan. The HMO aspect means that you cannot go to any out-of-network providers; you must choose your doctors from within the in-network system.

Medicare

If you have Medicare, you will need to sign a special contract with me because I have Opted-Out of Medicare. I am happy to explain this if you ask. Please see What about Medicare?

Other Medical Funding

If you have an FSA (Flexible Spending Account), HSA (Health Savings Account), HRA (Health Reimbursement Arrangements), or MSA (Medical Savings Account), these funds can be used to pay for all kinds of health services, including mental health, which includes my services.