Making Sense of Out-of-Network Insurance Benefits
While we work hard every day to be in-network with more and more insurance companies, it’s possible that you may want to engage in out-of-network care with us. But paying for therapy doesn’t have to be complicated.
There are several key components to an insurance plan that determine when and for how much you will be reimbursed: your deductible, your coinsurance, and your allowed amount.
This information can typically be found in an explanation of benefits that was mailed to you when your plan started, or on your insurance company’s online portal. You can always find this information by calling the number listed on the back of your insurance card. If Two Chairs is out-of-network with your plan, before starting care, our Care Coordination team can also help find this information for you.
Deductibles and Coinsurance
A deductible is the amount of money one must pay out-of-pocket before insurance benefits kick in and typically reset on a yearly basis. Deductibles vary depending on plan and insurance company. They are also often different for in-network and out-of-network services, and can range from $0 to $24,000. Any healthcare payments that you make for out-of-network services and file with your insurance company count towards your deductible.
Once your deductible has been met, the coinsurance rate will be applied to the cost of services, which reduces your total responsibility as the patient. If you have a coinsurance rate of 30%, that means that you are responsible for paying 30% of the cost of your appointment and your insurance company will reimburse you for the remaining 70%. For example, if your therapy appointment costs $100 and you have a 30% coinsurance, your insurance company should cover $70.
Seems straightforward enough, right? Not quite — there is one more piece of the reimbursement equation, and this is where things get tricky. This is the “allowed amount” also known as, “eligible expense” or “negotiated rate.”
Allowed Amount
Often the most difficult parts to understand about insurance benefits is the allowed amount. The allowed amount is a predetermined, maximum cost of different health service. This value is set by your insurance company, and often varies by zip code, service, and provider type.
For example, the same client might have a $130 allowed amount for a 45 minute therapy session in San Francisco, but a $120 allowed amount for a therapy session in Oakland — even if the cost of your appointment was $190. Unlike deductibles and coinsurance, this number is neither listed nor made readily available by insurance providers, making it extremely hard to quickly understand your benefits.
The allowed amount means most insurance companies severely undervalue out-of-network health services, and clients are stuck paying the difference between the actual cost and the allowed amount for their services. We’ve seen a wide variance in allowed amounts (from $60-$300), which means actual reimbursement varies significantly from client to client.
For example, for a $205 Two Chairs appointment, if you have an allowed amount of $120 and a coinsurance rate of 30%, you are responsible for paying (30% of $120) + ($205-$120) = $121 per appointment after you’ve met your out-of-network deductible [see figure below]. While insurance companies won’t disclose our clients' allowed amounts to us, we give our clients guidance on how to ask for allowed amounts from their insurance companies, so we can help get the most accurate reimbursement quote possible.
Now that I understand my benefits, how do I get reimbursed?
Unfortunately, reimbursement for out-of-network care is not instantaneous; clients must pay the full amount to their provider upfront, and then submit an insurance claim to get reimbursed, after the fact.
Like understanding benefits, submitting insurance claims is another challenging aspect of out-of-network care. Insurance companies have different processes, forms, and addresses, making the process hard to navigate. Especially in times of emotional and mental strain, filling out claims paperwork and ensuring that they’re sent to the right place can be frustrating at best. To submit your claim, you need a superbill, which is an itemized receipt you receive after your appointments.
If you choose to do therapy at Two Chairs but are currently out-of-network, we are happy to provide you with superbills for each session upon request. Each superbill will have all the information you need to quickly submit your claim, making the process as streamlined as possible so you can focus on your care. And, our Care Coordination team is here for you to answer any questions along the way.
Any numbers in this post do not necessarily reflect Two Chairs pricing.
