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Debunking Health Insurance Benefits

If I had a dollar for every time I heard “Physical Therapy is too expensive” or “My deductible is too high”, I would have a lot of dough… Unfortunately, these phrases are common nowadays with how the model of healthcare is changing. Gone are the days of no deductibles, 0% co-pays that you used to see with companies like Microsoft. It means that we need to change the way we think about our health insurance and benefits to better serve ourselves in the future and take on more responsibility for our wellbeing.  

Can you really put a price on your health? That slight knee pain now, might mean an early knee replacement later, discontinuing running at an earlier age, and increasing heart risk as your cardiovascular health goes down. That occasional urinary leakage with laughing now, could mean wearing depends later in life. Obviously, these are extreme examples, but how we move through life and how we take care of our bodies is going to have a direct correlation on our happiness and our ability to enjoy life as we age. 

Here’s the real deal… you need to budget for your health on a monthly basis, even if you are young and healthy!

Here is how to do that:

  1. Go to your insurances website and create an account and sign in -OR- call the 1-800 number on the back of your card. 
  2. From here you will be able to look up or ask for your benefits. You will need to: 

Find your Deductible

The total amount you need to spend before your benefits start to kick in, this number can range anywhere from $200-10,000+ depending on if you have a Family Plan vs and Individual Plan and whether you have a High Deductible Plan or a Catastrophe Plan. 

Find your CoInsurance % or Co-Pay

This number is the amount you will pay per visit, it may vary depending on the type of visit, but find the most common number used. A common example would be a 20% co-insurance or a $40 co-pay. 

Find your Max Out-of-Pocket

This is the amount of money you will have to spend before your insurance company covers you at 100%, it is often seen as an emergency number, meaning that if for some reason you were to be hospitalized or have a large injury, you would not have too large of a hospital bill. 

  1. One you have all three of those number’s you can create a budget. We are going to use mine as an example.
    1. My Deductible is $2000, I have a 40% Co-Insurance, Max Out-of-Pocket is $5000. My plan starts over every year in January, but some plans may re-set at a different time throughout the year. 
      1. I know I will at least need to save up $2000 in a given year so that I can meet my deductible. After that I subtraction the $2,000 from the $5,000 to get $3,000, and then I know that I will have to pay 40% of those visits/procedures, etc. for a total of $1,200. 
      2. $2000 (my deductible) + $1200 (my 40% co-insurance) = $3,200/12 = $266 per month
      3. The $3,200 is also the given max I will have to spend in a year if I did end up being hospitalized or had a major accident that cost more than my out-of-pocket
  2. Best way to save this money:

Personal Savings Account

If your company does not offer a Health Savings Account or a Flexible Spending Account, making a separate account to put money into on a Monthly basis is always a good option. THE BEST PART: if you stay relatively healthy, you will have extra savings or fun money to spend the next year, or you can keep the amount around for the year after and not have to put any money aside! (Remember, your benefits might change each year, so you should re-calculate this number every time your insurance starts over.) 

Health Savings Account: 

If your work offers a HSA, take advantage, this works exactly like a personal savings account, except that it is TAX FREE! And in some cases, can be invested while it sits there. In this case, you are given the option to tell your employer how much money you would like to put in here on a monthly or yearly basis, and you will know exactly what that number should be now! HOWEVER: If your employer is contributing to this then, all you have to do is do the math. Take my scenario, I know the max I could pay a year is $3,200, but my employer is contributing $1000, that means I only need to put aside $2,200 per year or $183.33 per month into my HSA. This money can be used for a variety of medical treatments, even ones that may not be included in your benefits, such as medical massages, medications, reading glasses, etc., It can also be used to go out-of-network to a specialist or use a Cash Pay PT service that you would have normally stayed away from in order to stay in-network. This money rolls over every year and you can choose to build it up or contribute less each year, depending on if you want to invest money, or save it up for an emergency. 

Flexible Spending Account: 

This is also an account that is offered by an employer, also something to take advantage of and is also TAX FREE! However, this account is different in that you must spend all of this money by the end of the year, occasionally, they will let you use this beyond the first of the year for up to 3 months, but read the fine print because it disappears after that. It also still allows for you to pay for other medical items that maybe you would not have normally budgeted for, but you may want to put less in here if you are not utilizing your insurance as much. For example, in my scenario, instead of putting the full $3,200 into the FSA for the year, I might do just the amount of the deductible, $2000, and then if I do go over that I will pay my 40% co-insurance as it comes. If you know you are going to have shoulder surgery, you might do the opposite and put in the full amount.  

By planning to meet your depictable and starting that plan at the beginning of the year you do a few things:

  • You take away the barrier to seeking treatment by reducing that scary deductible into an achievable monthly cost, this means you will go to your doctor when you need to, fully participate in therapies, get new glasses, etc, without hesitation!
  • If you stay healthy, you end up with an emergency fund, fun money, investment money and so much more.
  • You open up avenues to spend healthcare money where you want to, vs only staying in-network 

All and all, you will not regret having this extra money set aside and you will be healthier for it!

At Therapydia, we also help you plan for your care by letting you know the cost of your visits calculated by using your insurance benefits so that you can budget for your care better. 

When you schedule, we let you know:

  • How many PT visits per year you have
  • Does PT require a referral
  • What your deductible is and how close you are to meeting it
  • Your co-insurance or co-pay
  • And if you haven’t met your deductible, we estimate how much each visit will cost you until you do

We also keep a card on file so that you don’t fall behind on payments as well has breaking down your deductible each session so that you aren’t hit with a $2,000 bill!

Lastly, if you do need to do cash-pay or out-of-network billing, we do the math for you as to which is the most inexpensive option and offer superbills to submit for reimbursement so that the visit goes towards your deductible. 

To end here are some more definitions of health care benefits that are important to know:

Premium: This is the amount you and your Employer pay per month to have a particular health plan, your employer may pay 100% of this, but most likely you pay a portion of this in each of your pay checks.

Superbill: This is a document that includes the date of service, information about the provider, the billing for that visit and more that can be used in addition to a form from your insurance to submit for a visit or service that was a cash pay service. 

Self-Reimbursement: This is the process of looking up on your insurance company’s website and looking for the form or tab called “Submit a Claim.” The website will then lead you through instruction on how to submit information to the insurance company in order to be reimbursed for a visit. This would be sent in along with the superbill.  

Authorization: Some insurance companies hire a 3rd party authorization company to manager services provided, this is something that the provider will fill out for you when needed, but you may be sent notifications as to whether visits and procedures were approved after they submit. 

Specialist vs Primary: Often times different co-pays are applied to your primary care vs a specialist, if you are wondering what the provider considers themselves, ask the front desk, they will know if the provider is considered a Specialist or a Primary Care. 

In-Network Benefits vs Out-of-Network Benefits: We discussed saving for in-network benefits, but out-of-network benefits can be different than in-network, meaning they may have higher deductibles, higher co-insurances. For example, instead of $2000, it may be $4000 and instead of a 40% co-insurance, it may be a 60% co-insurance. This means that for those providers out of network, you may not meet your deductible as fast and you may be responsible for more of the bill. It is again important to know these numbers so you can budget for a provider that is out-of-network.

ICD-10 Code: This is the code use to bill for a given diagnosis, such as shoulder pain.

CPT Code: This is the code used to describe the services build for, such as manual therapy, therapeutic activities, etc. 

NPI: This number is a national number assigned to each provider or group of providers and is often used to track providers that are in/out of network, credentialing, licensing, etc. 

Tax ID Number (TIN): This is the number for each office that is used for billing purposes to the insurance company to distinguish one group from the next. 


By Kelsey Dehmer, PT, DPT, OCS | Therapydia Ballard

Jessica Jones

Physical Therapist

Jessica recently moved to Seattle from Boston, MA and is excited to join the Therapydia team. Her treatment experience includes orthopedics, sports medicine, pediatrics, and vestibular therapy. Jessica received her Doctorate in Physical Therapy from Northeastern University in Boston, MA in 2016. She has completed the Pediatric Physical Therapy Residency at Boston Children’s Hospital and is in the process of completing a Comprehensive Vestibular Rehabilitation certification. Jessica believes in empowering and inspiring patients to take control of their health through education, movement, and exercise. She enjoys treating patients of all ages and levels while utilizing soft tissue techniques, neuromuscular re-education, balance training as well as therapeutic exercise. In her free time, Jessica enjoys yoga, dancing, kayaking, and hiking with her dog!


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