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Fast FactsInsurance FAQs

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We don’t expect you to be an insurance expert – that’s what we’re here for – but there are some things it’s good to know for yourself. Keeping up with the basics can be challenging though, because the ins and outs of insurance policies change – meaning what is and isn’t covered – as state and federal policy makers alter, update, or replace laws and regulations. We keep up to speed on the latest developments to eliminate confusion and get you on the path to wellness. We’ll read the fine print for you – but you can brush up on the essentials with our helpful glossary below.

FAQsHere’s a quick list of essential facts you need to know:

What do the terms HMO and PPO mean?
HMO refers to a Health Maintenance Organization and PPO refers to a Preferred Provider Organization. Both HMO and PPO plans set up networks of providers for your health care needs. People with HMOs generally need a referral from a primary care physician for specialty treatment, whereas people with PPOs do not. HMOs typically have smaller networks, lower deductibles and co-pays, while PPOs have larger networks and higher copays and deductibles. HMOs are growing less and less common every year. Most employer-provided insurance plans are PPOs.
What do the terms In-Network and Out-of-Network mean?
Insurance providers enter into contracts with groups of doctors, hospitals, urgent care facilities, and treatment centers to create a network. The basic concept of a network is that insurance companies negotiate fixed rates for specific services with a group of health care providers – your network – and encourage you to use those providers. Out-of-Network providers are any health care providers who do not have a contract with your insurance company. In-Network deductibles and co-pays are typically less expensive than Out-Of-Network deductibles and co-pays
What’s a deductible?
A deductible is the annual dollar amount you pay for health care services before your insurance benefits begin covering your costs. For example, if you have a $1,000 deductible, you pay the first $1,000 required for a service. Your insurance company pays whatever percentage of expenses specified by your plan after you pay the initial $1,000. Monthly premiums and co-pays do not count toward your annual deductible.
What’s Coinsurance?
Coinsurance refers to the provisions in your plan for covering costs for a specific service after you meet your annual deductible. You’ll see numbers like 90/10, 80/20, or 70/30 in reference to coinsurance. These numbers are simple: for example, if you have an 80/20 coinsurance plan, your insurance company pays 80% of the cost for a service after you meet your deductible, and you pay 20% of the cost for that service after you meet your deductible.
What’s a Copay?
A copay is a predetermined, fixed dollar amount you pay for a specific health care service. Your copay amount varies depending on your policy and the service you receive. For instance, if you have a $40 copay for a mental health office visit, you pay the $40 – typically at the time of service – and your insurance company pays the rest.

In-Network or Out-of-Network?

While we work primarily with in-network providers, we have experience working with patients who aren’t in our network. We’ll get you the details on your out-of-network benefits – deductibles, coinsurance, copays, etc. – and help you understand your level of financial responsibility before you commit to a program at Pinnacle Treatment.

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