How to Determine your Insurance Coverage for Cost of Care
In-network providers are providers that have contracted with your insurance carrier to provide health care services at a pre-negotiated rate. Patients are encouraged to seek care from in-network providers to maximize their benefits and reduce their out-of-pocket costs. For example, if your insurance carrier is Cigna, we encourage you to book therapy and psychiatry appointments with providers listed as accepting Cigna.
Out-of-network providers are providers that do not have a pre-negotiated rate with your insurance carrier. Patients seeking out-of-network services will be subject to higher deductibles and higher out-of-pocket costs including but not limited to, denied services based on your benefits. As a courtesy, we will bill your services to your insurance carrier, however, please be aware you will be responsible for a higher out-of-pocket cost.
Clarity Clinic participates with Aetna, Blue Cross Blue Shield of Illinois, Cigna, and UnitedHealthcare.
Please understand that although we may be in-network with your plan if you have not met your copay, deductible, and/or out-of-pocket expenses, Clarity Clinic will bill you for those services after your insurance carrier processes your claim.
It is recommended that once you have verified that we take your insurance plan, you review the provider’s profile you wish to schedule with to ensure they accept your plan.
After determining you are in-network with Clarity Clinic, we recommend you check the description of your plan benefits listed under behavioral health services or coverage for mental health services. If you are unable to find this, please contact your insurance carrier for further clarification.
Please understand that although we may be in-network with your plan, if you have not met your copay, deductible, and/or out-of-pocket expenses, Clarity Clinic will bill you for those services after your insurance carrier processes your claim.
How To Find Out What Your Behavioral/Mental Health Benefits Are
A Step-by-Step Guide to determining your benefits
- Call the customer service number located on the back of your insurance card or contact your HR department to obtain more information on your mental health care benefit coverage.
- Ask the following questions:
- Do I have coverage for outpatient mental health or behavioral health services in Illinois?
- Do I have a deductible for outpatient mental health services? What is the deductible amount?
- A deductible is a fixed amount the patient has to pay each year before their insurance company will begin to cover the cost of a covered service.
- Do I have a copay or coinsurance?
- A copay is a fixed amount the patient pays each visit to share the cost of a covered service with the insurance company. Coinsurance is a fixed percentage the patient is expected to pay once their deductible has been met.
- Are my mental health services covered through another carrier?
- Do I need to obtain prior authorization or a referral to receive mental health services?
Health Insurance Terms Explained
A deductible is a fixed amount the patient has to pay each year before their insurance company will begin to cover the cost of a covered service. This means that if a patient has a $2,000 yearly deductible, the patient will need to pay $2,000 first before the insurance company will begin to pay on covered services. Patients who have a family deductible at times will meet the family deductible before their individual deductibles. In these instances, the patient’s health insurance would then pick up the cost of those covered services.
If your mental health benefits are “subject to deductible,” this means you will pay out of pocket until the deductible has been met.
If mental health services are not “subject to deductible,” then insurance will pay their portion right away and you will pay whatever your plan holds you responsible for.
A copay is a fixed amount the patient pays each visit to share the cost of a covered service with the insurance company. Copays can vary in amount based on the type of service you are receiving and the type of plan you have. You will find that copays are higher for specialists, ancillary services (MRI, CT, etc.), and emergency room visits.
Copays range anywhere from $10 up to $100 per visit. Copays are typically displayed on the front of the patient’s health insurance card but may not always be available. On occasion, you will find that a copay may not always apply to a patient’s visit, so check your benefits before seeing one of our providers.
Coinsurance is a fixed percentage the patient is expected to pay once their deductible has been met. Patients’ percentage of coverage may vary depending on the type of plan they select. Typically, a plan will cover 80/20, meaning the insurance company will pay 80% of the claim, holding the patient responsible for the remaining 20%.
For example; a patient has an out-of-pocket max of $3000.00. When the insurance processes claims, they will continue to apply that 20% to patient responsibility till they meet the $3000.00 max. Once that out-of-pocket max has been satisfied, the insurance company will begin covering eligible services at 100%. This out-of-pocket max resets every calendar year like the deductible.
On average, we should receive a payment within 30-45 days if there are no issues with the claim. Some common payment delays we have encountered in this process are eligibility-related or a request for additional documentation. In these situations, Clarity Clinic will provide the necessary information to the insurance carriers. This process can further delay payment and resolution of your services by an additional 90-120 days depending on the insurance carrier.
Clarity Clinic does not accept Medicaid.
An HMO is a Health Maintenance Organization plan. The coverage is limited to providers contracted with those HMO plans. There are no out-of-network benefits under HMOs. Patients MUST receive a referral from their Primary Care Provider for all services outside of the PCP’s treatment. Referrals must indicate the referring doctor and the treating clinic along with the referral reason. (Example: PT’s PCP, John Smith, MD referring PT to Clarity Clinic for ADHD treatment).
Clarity Clinic does participate with a few HMO plans. To identify which HMO plans we participate with, please contact Clarity Clinic for further details.
A PPO is a Preferred Provider Organization plan that allows the patient more flexibility and control over their care. This plan allows the patient to choose their providers and hospitals. A PPO has both in and out of network benefits and does not require a referral but the PPO does have a higher premium due to these options.
Clarity Clinic does participate with select PPO plans. To identify which PPO plans we participate with, please contact Clarity Clinic for more information.
The Mental Health Parity and Addiction Equity Act of 2008 was a momentous change in coverage for mental health issues. The act essentially mandated mental health and substance-use coverage to be comparable to physical health coverage by stating that insurance policies that offer mental health coverage must treat it the same as they do other medical coverage. The law intended to make mental health and substance-use care more accessible to the general population.
Federal Parity Law applies to employer-sponsored health coverage for companies larger than 50 employees, all coverage purchased through health insurance exchanges created under the Affordable Care Act, the Children’s Health Insurance Program (CHIP), and the majority of Medicaid programs.
The law states that if mental health benefits are offered under the provider’s coverage, they cannot have more restrictive requirements than those that apply to physical health benefits. So, the parity law does not require insurers to provide mental health benefits, but the majority of insurance providers offer plans including mental health benefits.
If you’re curious as to whether your health insurance plan offers mental health coverage, contact your insurance provider directly to discuss what coverage may be available.
However, Federal law does not require health insurance providers to provide mental health benefits, it merely states that if coverage is offered, it must be comparable to physical health insurance benefits. Your mental health is just as important as your physical health.