Thursday, January 22, 2015

Deductibles, Maximum out of Pockets, Insurance…Oh My!

Insurance is confusing and trying to find services for addiction that accepts insurance is complicated.  Oh sure, it’s accepted but typically is considered out-of-network which is more costly.  I educate my employees every year at open enrollment on how group insurance works and then I explain once again when they actually have to use it for something large and the bills start coming in.

With group insurance, there are “buckets” to fill.  The first bucket is the deductible bucket.  Typically expenses such as staying in the hospital, out-patient or in-patient surgeries, x-rays, MRI's and CAT scans start filling up this bucket.  Once this bucket is filled you are done paying for these things for the year.

The second bucket is your co-pay bucket.  Any doctor co-pays, prescription drug co-pays, urgent care co-pays fill this bucket.  Once the co-pay bucket is filled you are also done paying for these things for the year.

"Maximum out of Pocket" is the most you can be charged for during the year.  Most group plans go by the calendar year (January through December) but not all.  The Maximum out of Pocket is the deductible bucket plus the co-pay bucket added together.

Now, if you stay “in network”, your deductibles and co-pays are considerably less.  If you are “out of network” a lot of the time the deductibles are doubled.  Also, “in network” and “out of network” buckets are separate.  They do not combine.  So, if a facility accepts insurance, make sure you understand if they are filing the insurance in-network or out-of-network.  This has nothing to do with in-state or out-of-state.

Sometimes, calling your insurance company is a helpful first step as they can provide the names and contact information of facilities that are in the network.  Insurance is a complicated world and I believe it will continue to befuddle people for years to come.