Let's Talk Insurance: Key Vocabulary Terms to Understand your Benefits
An insurance policy is a contract between you and your insurer, and includes a lot of minutia that can be difficult to decipher. The details of what is and isn't covered, and under what specific circumstances, can seem boring until you actually need to use your insurance, at which point it can quickly become frustrating and unpredictable.
So, what should you know if you're looking to use your insurance benefits for acupuncture? When it comes to using your insurance, understanding the details is a lot easier when you understand the language most commonly used to describe your coverage.
Here are some key terms and their definitions, to help guide your conversation with your insurance company.
1.In Network/Out of Network Acupuncture Coverage: Start Here!
Providers who are contracted with an insurance company are called "in network providers." This means they have agreed to work with the insurance company on the cost of services, which usually means savings are passed on to you. Some plans also offer out of network benefits. Seeing an out of network provider may be somewhat more expensive than an in-network provider, but if you have this coverage it will give you more provider options. At this point in time, acupuncture is not a standard benefit on each and every insurance plan, so a call to your insurance company is a good starting point. The first question we recommend asking is, "Do I have in-network and/or out-of-network acupuncture benefits on my plan?"
If you have in-network coverage only, you will need to find a provider who is contracted with you plan. At Sparkes Acupuncture, we are in-network with our local Blue Cross Blue Shield. While we accept multiple other insurance plans, we participate as an out-of-network provider.
If you do not have coverage, we offer a TOS (Time of Service) discount that can be applied only when paying for services on the same day as they are performed. This discount cannot be combined with insurance billing, though a superbill is available upon request. Call our office for more information about our TOS discount for people who are not using insurance.
2. Deductible: Out of Pocket Cost Requirements
If you made it through the first question, and the answer is yes, then congratulations! You now know you have acupuncture benefits. The next question to ask is about your plan's deductible. A deductible is an amount that will need to be paid out of pocket (by you) before your insurance company starts to pay anything at all. Some deductibles are low, (ranging from zero to hundreds of dollars) and some deductibles can be extremely high (in the thousands). It's important to know what your deductible is, because you'll be responsible to pay for any services (acupuncture or otherwise) you use before you've met your deductible.
One more thing to note: If you have both in-network and out-of-network benefits, you may have a different deductible for each.
3. Copay/Coinsurance: Whats the difference?
A health insurance plan usually has either a copay or a coinsurance, which is the amount you are responsible for after your deductible has been met. A copay is a set dollar amount that must be paid for health services each time you use them. This is usually charged per visit, regardless of services performed/codes billed by the provider. A coinsurance is a cost sharing arrangement with your insurance, in which you are responsible for a certain percentage of the cost of services. This amount can be variable, depending on what health services you are receiving at your visit.
4. Provider Type: Who Performs the Health Services
Provider type refers to the license type of the medical provider performing health services. In our office, our acupuncturist is a Licensed Acupuncturist (L.Ac.).
Some insurance companies or plans have restrictions on which license types are allowed to perform which services. These restrictions are not necessarily in line with what a provider is licensed to do.
While most insurance that covers acupuncture will cover a Licensed Acupuncturist as the provider type, some require a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) to provide or supervise acupuncture services. This is true for certain Medicare and Medicaid plans.
While this is not a common issue, it is one to be aware of when understanding your insurance coverage. If your plan requires an MD/DO to perform services, it is best to ask for a list of providers who are in-network with your plan.
5. Diagnosis Restrictions: What Can be Treated with Acupuncture
While acupuncture is used for many different reasons (and has been for thousands of years!), insurance companies keep their own guidelines on when and why they will/will not cover acupuncture services.
Any insurance that covers acupuncture will have restrictions on what reasons you are allowed (or not allowed) to receive treatment, based on the insurance company's definition of what is "medically necessary." While each insurance company and plan may be different, acupuncture is most commonly allowed by insurance for pain management as well as nausea.
One or more diagnosis codes (also known as "ICD-10 codes") will be used when sending a bill to your insurance. These codes describe your chief concern for receiving acupuncture treatment, and must be considered "medically necessary" for acupuncture treatment.
It is a good idea to ask your insurance, "Do I have any diagnosis restrictions for acupuncture treatment?" Common answers may include "Pain Management Only" or "No restrictions except for...xyz."
Common codes include:
M54.50 Low Back Pain
M54.2 Cervicalgia (Neck Pain)
6. Visit Limit: How Many Sessions are Allowed
This one is relatively straightforward: the Visit Limit is how many sessions your plan allows you to have per calendar/plan year.
Visits are still subject to the other restrictions mentioned above, like the diagnosis codes and the deductible.
If your plan has both a high deductible and a visit limit, it is important to know that in most cases, the visits will be used during the time the deductible is being met (not after the deductible is met). Another common policy is that "visit limit is based on medical necessity." In short, this generally means that if progress is being shown, treatment may continue. A company's Medical Policy Bulletin may have more information on what type of improvement needs to be shown for treatment to continue. "Medical Necessity" does not mean visits are unlimited, and visits for preventative care are generally not allowed.
When you call your insurance company, remember to take notes and always take down a reference number at the end of the call. We are happy to do what we can to help you understand your coverage, and routinely call insurance companies to ask the questions outlined above.
We hope that understanding the above terms help to empower you to enact a care plan that you understand, and is in line with your budget & wellness goals!
Disclaimer: the above information is for informational purposes only, and we hope it serves you as a starting point to understand insurance in general. Insurance has a lot of nuance, so we do not assume any responsibility or liability for errors or omissions in this blog post. Your insurance coverage is a contract between you and your insurer, and we do not claim to understand the details of your policy in this post. Your use of the above described method of understanding insurance and calling to verify your benefits is at your own risk and responsibility. Some of this information may not apply to you, or may be different than described. The author's views are her own.
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