Good Faith Estimate Notice
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
•Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
•If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
•Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
•Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
•If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
•Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Understanding Your Health Insurance Policy
Key Terms
Deductible
A deductible is a set amount you have to pay every year toward your medical bills before your insurance company starts paying. It varies by plan and some plans don't have a deductible. Your plan has a $1,000 deductible. That means you pay your own medical bills up to $1,000 for the year. After that, your insurance policy will start paying for their share of medical services provided to you.
Copay
A fixed payment for a covered service, paid each time a covered medical service is accessed. It may range from $10 per service to $100 or more for ER visits or hospital stays.
Coinsurance
A healthcare cost sharing between you and your insurance company. The cost sharing ranges from 80/20 to even 50/50. For example, if your coinsurance is 80/20, that means that your insurer pays 80% of the allowable rate for any covered medical expenses and you pay the remaining 20%.
Allowable/Contracted Rate
This is the maximum price your insurance provider has decided a covered service should cost. In network providers have agreed to accept this amount, even if their published rates are higher. Out of network providers may charge you their full fee
Out-of-pocket maximum
The most you'll have to pay during a policy period (usually a year) for health care services. Once you've reached your out-of-pocket maximum, your plan begins to pay 100 percent of the allowed amount for covered services. A typical out of pocket max is a pretty high number, so unless you have surgery or a serious illness requiring a lot of treatment, it is unlikely that you will reach this point.
In Network Provider
In network refers to providers or health care facilities that are part of a health plan's network of providers with which it has negotiated a discount. This discounted price is the “allowable or contracted rate.”
Out of Network Provider
An out-of-network provider is one which has not contracted with your insurance company for reimbursement at a negotiated rate. Some health plans, like HMOs, do not reimburse out-of-network providers at all, which means that as the patient, you would be responsible for the full amount charged by your doctor.
Out of Network Benefits
If your policy includes out of network benefits, the amount covered is typically based on your insurance company’s allowable amount for that service, not the fee charged by your provider. For example, if your provider charges $100 for service, and out of network services are covered at “60%”, do not assume insurance will pay $60. If their allowable amount is $50, they will only pay $30. The remaining $70 of the provider’s $100 fee is your responsibility. Oftentimes, out of network providers will require payment of the full $100 at time of service, and give you documentation to submit to insurance yourself, requesting that insurance company send you a check for the $30. It is important to note that some plans have a separate deductible that must be met before out of network benefits apply.
Important Questions to Ask
These questions will help you understand the specific details of your policy. Please refer to your policy handbook and/or call the member services # on the back of your insurance card. Ultimately, you are responsible for paying for any services that your insurance company refuses to cover. To avoid costly surprises, it is very important to fully understand your benefits.
If a provider you wish to see is not in network, ask about your out of network coverage
*** The health insurance industry is forever evolving. As such, this document is intended to highlight some common aspects of healthcare coverage. It is not intended to be an exhaustive list of all possible terms, clauses or scenarios. ***
Deductible
A deductible is a set amount you have to pay every year toward your medical bills before your insurance company starts paying. It varies by plan and some plans don't have a deductible. Your plan has a $1,000 deductible. That means you pay your own medical bills up to $1,000 for the year. After that, your insurance policy will start paying for their share of medical services provided to you.
Copay
A fixed payment for a covered service, paid each time a covered medical service is accessed. It may range from $10 per service to $100 or more for ER visits or hospital stays.
Coinsurance
A healthcare cost sharing between you and your insurance company. The cost sharing ranges from 80/20 to even 50/50. For example, if your coinsurance is 80/20, that means that your insurer pays 80% of the allowable rate for any covered medical expenses and you pay the remaining 20%.
Allowable/Contracted Rate
This is the maximum price your insurance provider has decided a covered service should cost. In network providers have agreed to accept this amount, even if their published rates are higher. Out of network providers may charge you their full fee
Out-of-pocket maximum
The most you'll have to pay during a policy period (usually a year) for health care services. Once you've reached your out-of-pocket maximum, your plan begins to pay 100 percent of the allowed amount for covered services. A typical out of pocket max is a pretty high number, so unless you have surgery or a serious illness requiring a lot of treatment, it is unlikely that you will reach this point.
In Network Provider
In network refers to providers or health care facilities that are part of a health plan's network of providers with which it has negotiated a discount. This discounted price is the “allowable or contracted rate.”
Out of Network Provider
An out-of-network provider is one which has not contracted with your insurance company for reimbursement at a negotiated rate. Some health plans, like HMOs, do not reimburse out-of-network providers at all, which means that as the patient, you would be responsible for the full amount charged by your doctor.
Out of Network Benefits
If your policy includes out of network benefits, the amount covered is typically based on your insurance company’s allowable amount for that service, not the fee charged by your provider. For example, if your provider charges $100 for service, and out of network services are covered at “60%”, do not assume insurance will pay $60. If their allowable amount is $50, they will only pay $30. The remaining $70 of the provider’s $100 fee is your responsibility. Oftentimes, out of network providers will require payment of the full $100 at time of service, and give you documentation to submit to insurance yourself, requesting that insurance company send you a check for the $30. It is important to note that some plans have a separate deductible that must be met before out of network benefits apply.
Important Questions to Ask
These questions will help you understand the specific details of your policy. Please refer to your policy handbook and/or call the member services # on the back of your insurance card. Ultimately, you are responsible for paying for any services that your insurance company refuses to cover. To avoid costly surprises, it is very important to fully understand your benefits.
- Do I have mental health benefits through THIS company (the one you are calling)?
- If not, what company are my mental health benefits through?
- If not, what is the customer service phone number for that company?
- Is the specific provider I am seeing / I want to see covered under my insurance plan?
- Is a referral or authorization required prior to using my benefits?
- If yes, get an authorization and write down: my authorization # is ________, covers_____# of appointments, and expires on (date) _____
- What is my annual deductible?
- When does my deductible reset? (January, July, etc)
- Are my mental health appointments subject to deductible?
- Have I met my deductible?
- Do I have a co-pay for mental health office appointments? If so, what is it?
- Do I have a co-insurance for mental health office appointments? If so, what is it?
- Are video visits for mental health services (therapy/med management) covered?
- If video visits are covered, are providers required to use a specific platform (Teladoc, MDLive, DrOnDemand) that my provider may not be in network with?
- Do I have prescription drug benefits?
- Are my prescription benefits subject to deductible?
- How much do my current medications cost?
- What is my copay/coinsurance for each tier of medication?
If a provider you wish to see is not in network, ask about your out of network coverage
- Do I have a separate deductible for out of network services? If so, how much is it?
- What is my coinsurance for out of network office visits?
- Is my coverage the same for prescriptions or diagnostic testing (labs, imaging, etc) ordered by an out of
network provider?
*** The health insurance industry is forever evolving. As such, this document is intended to highlight some common aspects of healthcare coverage. It is not intended to be an exhaustive list of all possible terms, clauses or scenarios. ***
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