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.
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