UNDERSTANDING HEALTH PLANS
HEALTH MAINTENANCE ORGANIZATION (HMO)
- Low premium costs.
- Need to see a Primary Care physician first. The primary care physician is the gatekeeper for al specialized services and medical investigations.
- Need a referral from a doctor for physical therapy services, including a referral authorization number prior to seeking physical therapy services
PREFERRED PROVIDER ORGANIZATION (PPO)
- Can see any specialist without a referral.
- Encourages subscribers to seek services within the network, but subscribers can see out-of-network providers.
HIGH DEDUCTIBLE HEALTH PLAN (HDHP)
- A high deductible health plan that is usualy a PPO plan.
- Plans have lower premium costs but higher deductibles.
- HDHP plans often have a Health Savings Account (HSA) that the subscriber can use to pay for copays, co-insurance, and deductible costs
EXCLUSIVE PROVIDER ORGANIZATION (EPO)
- Low premiums.
- Subscribers can only see providers within the network.
- The EPO plan does not cover costs for out-of-network providers, meaning patients have to pay self pay for services received from a provider that is out of network.
POINT OF SERVICE PLAN (POSP)
- Combines features of both HMO and PPO Plans.
- Primary Care Physician establishes care for specialized services PCP must generate a referral, with a referral authorization number to seek Physical Therapy Services.
- Can see both in network and out of network providers.
HEALTH INSURANCE COSTS
Understanding healthcare coverage can be complicated. Below is an example to improve understanding of insurance costs for physical therapy services.
In the example below, the patient’s plan has a deductible of $500, copay of $30, co-insurance of 20% and an out of pocket maximum of $2000.
Follow the scenario with a physical therapy service cost of $120 per visit
DEDUCTIBLE
- Set Dollar amount to be paid by you before insurance contributes.
- Total Bill- $120
- You pay $120
- Insurance Pays: $0 until deductible is met.
- After $500 is met, insurance will start contributing.
COPAY
- Set dollar amount that you pay per visit after deductible is met.
- Total Bill- $120
- You Pay – $30 per visit until out of pocket is met.
- Insurance pays-$90 per visit.
CO-INSURANCE
- Percentage of the total bill, that is paid per visit after deductible is met.
- Total Bill: $120
- Co-insurance (20%);You Pay : $24
- Insurance Pays (80%): $96
OUT OF POCKET MAXIMUM
- Maximum threshold to be paid ($2000) in a calendar year(co pays, co-insurance, deductibles).
- Insurance Pays 100% after maximum is reached.
- OOP Maximum reached.
- Total Bill -$120
- You pay: $0
- Insurance Pays- $120
Disclaimer
The above information is for educational purposes only. Your actual coverage and exact fees will vary based on your individual insurance plan, coverage, and costs met at the time of claim submission. To get accurate details about your benefits, please call the number on the back of your insurance card and ask your member representative about your “physical therapy, outpatient, office visit” benefits.