With the New Year upon us, along with celebration and new year’s resolutions, it often means changes with insurance!
Whether your plan benefits have reset, you have changed plans entirely, it is important to understand your benefits. If your plan has changed, it is crucial that you inform our office ASAP to prevent any issues with processing of claims.
We are happy to perform limited benefit checks, but the results of those are not guarantees of coverage.
Connect the Dots cannot guarantee benefits, so it is ultimately the patient/guardian’s responsibility to understand the scope of their plan. Your benefit summary will list any exceptions and exclusions that may not be relayed during a routine benefit check.
It is also important to understand your plans deductible, co-pay or coinsurance requirements, along with any visit limitations.
If your plan resets in the calendar year (01/01), that means that the accumulations towards deductible, out of pocket maximums and visit counts will be back to 0.
Coverage termed or benefits not what you hoped? We offer self pay due at the time of service. Give our office a call for more details!
Still wondering what this all means? In order to help with the process, we have included a helpful guide to use when verifying your coverage.
Key terms
Deductible: a specified amount of money that the insured must pay before an insurance company will pay a claim.
Co-Pay: a specified amount of money that is due at the time of service.
Co-Insurance: The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.
Out of Pocket Maximum (OOPM): The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
Obtaining Benefits
- Call the customer service number on the back of your insurance card.
- Ask the following bolded questions to obtain your benefits for Occupational Therapy, Physical Therapy or Speech Therapy (Sometimes these services are called Outpatient Rehabilitation.)
What is the individual deductible for my child?
If the deductible has not been completely met, the remaining amount will be billed to you, the client, before the copay or coinsurance applies.
Total:$________ Met: $________
Does the deductible apply for Occupational/Speech/Physical Therapy services?
❏ Yes
❏ No
What is the out of pocket maximum (OOP)?
Total:$________ Met: $________
Once the deductible is met, do I have a copay or coinsurance?
❏ Copay Amount: $____
❏ Coinsurance percentage:____%
Is there a visit limit?
❏ Yes,____ visits per year and ____ visits are remaining.
❏ No
When does the plan reset?
❏ Calendar Year
❏ Plan Year ____/____/____
Does my plan require prior authorization?
If the answer is yes, CTD will submit the authorization on your behalf. Please be aware that authorizations may impact the scheduling process.
❏ Yes
❏ No
Are there plan exclusions? _______________________________________________________________________
Don’t hesitate to ask your insurance provider any questions for better clarification regarding your coverage. They are the best equipped to answer questions specific to your plan.