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INSURANCE PLAN TERMS
Exclusive Provider Organization plans are similar to an HMO in terms of coverage, but you usually don't need to see a primary care physician for a referral before getting mental health services.
Health Maintenance Organization plans have a network of healthcare providers who agree to accept a certain level of payment for services they provide. You have to pick a primary care physician (PCP) whose responsible for coordinating any other medical care you need. To get a referral to another provider you have to see your PCP first. Monthly premiums, co-pays, and co-insurance are usually lower. However, while an HMO is generally more affordable, they don’t cover any out-of-network care, except in an emergency.
Point of Service plans are a hybrid of an HMO and a PPO. POS plans typically don’t have a deductible and have low co-pays. You pay less for the plan’s network of healthcare providers and more for providers outside the network. Like an HMO you have to have an in-network primary care physician who provides referrals to specialists. Like a PPO you can go to out-of-network providers.
Preferred Provider Organization plans allow you to receive care from any provider—in or out of your network. This means you can see any doctor or specialist, or use any hospital. You also do not have to choose a primary care physician (PCP) and they do not require referrals. You pay less if you use the plan’s network. You pay more if you go outside the network.
Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out-of-pocket.
While co-pays are a dollar figure, coinsurance is listed as a percentage. Once you’ve met your deductible, you are responsible for paying a percentage of each therapy session and your insurance company covers the rest of the appointment. Coinsurance rates are service specific, meaning that there is a specific rate for behavioral or mental health visits.
This is the fixed amount you are required to pay for healthcare services covered by your insurance plan. Copays are listed in dollar figures.
To get reimbursed with both in-network and out-of-network providers you usually need to spend a minimum amount on medical care before your health insurance coverage kicks in. After you pay your deductible, you usually only pay a copayment or coinsurance for covered services. Your insurance company pays the rest.
In-network therapists have a contract with your insurance company and have to abide by their rules.
Out-of-network therapists do not have a contract with your insurance company. This means they have greater flexibility where your treatment plan is concerned. Depending on your insurance plan you may be able to apply out-of-network benefits to cover some or most of the cost of your sessions. At the SAT Project we are all out-of network providers.
This is the money you pay directly for medical services.
This is the most you will spend on covered services during the policy year, after which your insurance will pay for 100% of the services covered under the plan.
The amount you pay the insurance company each month depending on your type of plan.
A referral is pre-approval or pre-authorization for services that is sent from your primary care physician (PCP) to a specialist.
If you are seeking out-of-network reimbursement, The SAT Project will give you a super-bill. This is essentially an itemized receipt for services that you send to your insurance company along with a claim form.
UCR (Usual, Customary & Reasonable)
The actual amount you are reimbursed by your insurance plan is not based on what a therapist charges per session. Instead, it’s based on a predetermined UCR rate that the insurance company sets based on your geographic location. For example, in New York City, the UCR rate for out-of-pocket psychotherapy is typically between $200 and $300.
The amount you need to pay a therapist if you cancel a session on short notice.
A 4-digit number used to signify a diagnosis. Therapists are required to assign you a diagnostic code if you are using insurance benefits to pay for therapy.
Outpatient Mental Health
This is a term you’ll see on an insurance summary and benefits. It means a therapy session that takes place outside of a hospital.
A 5-digit number that tells an insurance company what kind of services were provided in a session so they know how much to reimburse you.
On our Fees and Insurance page, you'll find additional answers to frequently asked questions about consultations, rates, and insurance filing as well as how to verify your benefits with your insurance company. Of course, if you have any other questions feel free to get in touch.