Insurance 101 - Understanding and Using Insurance
Navigating and understanding insurance can be confusing and frustrating. This blog post is meant to answer the most common questions people have when they seek psychotherapy services. There can be a number of exceptions and unique circumstances when it comes to getting and using health insurance. The following information is meant for educational purposes only and may not answer all of your questions. If you still have questions please contact your insurance provider or reach out to a MNsure navigator.
Where and how do you get insurance?
If your employer doesn’t offer insurance, you don’t qualify through your workplace, or you don’t want the insurance plan that’s offered at work, you can get insurance through the marketplace. In Minnesota this is called MNsure. On MNsure’s website you can look through available plans to find the best one for you and/or your family. If you need help with this, Minnesota has MNsure navigators that offer free assistance with getting enrolled in a healthcare plan through MNsure, including getting enrolled in Medical Assistance or MinnesotaCare.
What are the costs associated with health insurance?
There are costs associated with health insurance if you do not qualify for Medical Assistance. To maintain your health insurance you may be required to pay a monthly fee called a premium. The cost of the premium varies depending on what plan you have or choose. When you use your insurance to seek medical or mental health care there may be other costs associated with using your insurance, often referred to as out-of-pocket costs. This means that these are costs you are responsible for that your insurance will not cover - meaning it’s coming directly out of your own pocket. These costs include:
Deductible: this is the amount of money your insurance requires you to pay out of pocket before your insurance company will begin to cover any part of your medical costs. For example, if your deductible was $2,000 you are responsible for paying any medical expenses throughout the year with no help from your insurance company until you reach $2,000. Once you reach this amount, most insurance companies will then begin to pay a part of your medical costs. Please be aware that there may be medical or mental health services that do not fall under your deductible and may either be covered in full or may only require a copay. Common examples are annual wellness check-ups at the doctor.
Copay: this is a set amount of money that you owe the provider at the time of your visit. For example, if you have a copay of $30, each time you see your provider, you will be required to pay this amount at the time of the visit.
Coinsurance: after your deductible is met, your insurance will start to cover some costs of your medical and mental health treatment. The remainder that is left over after your insurance pays is often referred to as your coinsurance. For example, if you have a deductible of $2,000 and a coinsurance of 20%, this means that you will be solely responsible for your medical costs until you have paid out $2,000. After that, you will then be responsible for paying 20% of the medical bills while your insurance will cover the rest (80%).
If you want to better understand your own out-of-pocket costs, you can check your insurance card or contact your health insurance company to request this information.
What does it mean if a provider or clinic is in network or out-of-network? An important part of insurance to keep in mind is that not all treatments, services, clinics, or providers will be covered under your health insurance plan, meaning if you seek a service and it’s not covered under your plan you may be responsible for the entire cost of the service. This is often more expensive.
To better understand why this is more expensive let’s first talk about what it means for a provider or clinic to be in network vs. out-of-network. Insurance companies contract with certain providers and clinics to get a contracted, or discounted, rate for you. What this means is that instead of paying the full rate for the services you are receiving, you will have a discounted rate. If a provider or clinic is out-of-network or not covered by your insurance, you may pay a higher fee or the full fee for the service you are receiving. To find out if a provider or clinic is in network with your health insurance plan, contact your insurance company.
How does the process work for using my insurance with my therapist?
Before you meet with your provider: Your provider will ask for your health insurance information. It is your responsibility to understand your insurance plan and benefits, including any out-of-pocket costs and whether the provider is in network with your health insurance plan.
During your first appointment: Your provider may ask to take a copy of your insurance card. They will also collect any copay amount that you owe.
After the appointment: Your provider will submit the visit/claim to your insurance company, which can take weeks to process. Once your provider gets the claim back from your insurance company, they will then give you a bill for any amount you owe that your insurance did not cover.
What if my visit got denied by my insurance and my insurance is saying they won’t cover the service?
As soon as you are made aware of a service being denied please notify your provider. It’s possible that the reason it was denied could be remedied and the visit reprocessed with your insurance company. If the visit was denied and it cannot be remedied, you may be responsible to pay the full amount for the service you received. Common reasons to have a service denied with therapy:
Coordination of benefits: If you have two insurance plans you will need to notify these insurance companies so they are aware of each other and can decide which insurance plan should be billed first versus second. If you have not done this, a service can be denied as each insurance company is waiting for the other to pay first and will not talk to one another until you give permission and inform them of your two insurance plans. Sometimes insurance companies will think you have more than one insurance plan when that is not the case. If this happens, call your insurance company and notify them of this.
Insurance is inactive: If you lost your job, didn’t complete necessary paperwork in time, or did not pay your insurance premium, this can result in losing your health insurance. If you are on Medical Assistance or MinnesotaCare, you may be able to get your insurance reinstated by completing any missed paperwork that is required. If you missed paying your insurance premium, contact your insurance company to determine next steps. If you had a life event that led you to lose coverage, such as losing your job, you might be able to qualify for health insurance through the marketplace outside of the annual open enrollment period. Contact MNsure or a navigator for assistance and for more information.
Your health plan does not cover the service: Sometimes certain providers, clinics, services, or treatments are not covered by your health plan. When this happens you may be responsible for the full cost of the service or treatment.
As stated previously, the above questions tend to be the most common questions asked when accessing mental health services. If you have more questions about your insurance or using it to access mental health treatment, please contact your insurance company. Insurance can be confusing and difficult to navigate at times, but having a better understanding can feel empowering and help you to access the healthcare you need.
Written by: Sam Franklin, MA, LMFT