Understanding Insurance Benefits
Let’s face it – insurance benefits can be tricky to understand. We want to help you understand insurance jargon as it relates to your physical or occupational therapy.
Please note that any information provided here or quoted by any member of the MoveMend team is never considered a guarantee of coverage or payment. This information is intended solely to educate and answer common questions about health insurance terminology.
For details about your specific benefits, you will need to consult your insurance provider directly.
IMPORTANT: MoveMend has no relationship with Medicare and cannot provide Medicare-covered services, including medically necessary physical and occupational therapy, to beneficiaries. However, Medicare beneficiaries can take part in our personal training program as that is cash-based.
When a provider is in-network with an insurance company, they’ve signed a contract to treat patients enrolled in those health plans at lower rates. Providers typically have to apply to join an insurance company’s network, but not every provider is accepted. Some insurance companies keep their networks limited to a smaller group of providers in each area.
When a provider is out-of-network with an insurance company, they don’t have a contract to treat patients enrolled in those health plans at lower rates. Even if your provider is out-of-network, they can still bill your insurance plan. However, your rates and costs will likely be higher.
Your deductible is what you have to pay out of pocket before your insurance plan will begin making any payments for your treatments. However, there are some plans that don’t require a deductible to be met before they will contribute toward costs. Those plans typically require patients to make a co-pay (see below) at each visit.
This is a set dollar amount you’re required to pay at each visit. This will typically be your only financial responsibility for each visit if your claim is covered. Your co-pay usually applies only to the time spent with your therapist during your treatment session. Any equipment you need, such as splints, braces, or other medical devices, might have additional fees.
A co-insurance is a percentage that represents the balance you have to pay after insurance has made any payments or adjustments to your claim. Your co-insurance will apply after you’ve met your deductible. Since this is a percentage, your cost per visit will vary depending on the treatments provided at each session.
Your out-of-pocket maximum is the highest amount you’re responsible for paying when it comes to covered services within a certain period of time, usually one year. Once you’ve met your out-of-pocket maximum, your co-insurance and co-pay will no longer apply as long as any remaining treatment for the year is covered by your insurance plan.
This is the maximum number of visits that will be covered for a particular service over a given time period, usually one year. In many instances, insurance plans will combine visit limits for different services that may be provided at other facilities such as physical therapy, occupational therapy, massage therapy, chiropractic visits, and speech therapy. It is your responsibility to keep track of your visit counts during the course of your treatment with MoveMend. We are not responsible for tracking and knowing when you have reached or exceeded your allowed visits.
Some insurance plans require an authorization, or permission, to use and have your visits covered under your plan. We’re required to submit paperwork to an independent 3rd party company, most commonly Evicore, that has been selected by your insurance company. Evicore will provide guidelines to your insurance company about the number of visits that will be covered and the time frame that they can be used within. We’ll submit the appropriate paperwork but in the event that authorization is denied for visits that have already taken place, you will be responsible for paying for those visits not covered by your insurance plan in full.