It’s that time of year: open enrollment for health insurance. Since you may be choosing new insurance benefits, we here at LB Hand Therapy wanted to offer some insight into the different types of insurance plans.
- HMO: With a HMO plan, the insurance company provides a provider list that they participate with. You may find you have limited providers in your network, but with an HMO you must see a provider in your network. You also will need a referral for therapy from your primary care physician. And with an HMO, you will have a copay.
- EPO: An EPO is very similar to an HMO where you will have to choose from a specific list of providers. Typically with an EPO, you will not need a referral.
- PPO: With a PPO, you will also have a provider list, however you are not limited to that provider network. It is typically less expensive to see an in-network provider and you will likely have a copay. Depending on the insurance company you may have to pay more for an out-of-network provider. With a PPO, you may or may not need a referral based on the terms of your plan.
- Indemnity: With an indemnity plan, the insurance company pays a straight percentage of the bill and you as a patient will pay the other percentage, which is called a coinsurance.
- High Deductible Plans: A deductible is an amount of money that you as the patient will be required to pay. High deductible plan amounts start at $1,300 and can go up from there to $5,000. With this type of plan, you as the patient will pay for everything until you reach your deductible. Once you have met the deductible, depending on your plan, you are then typically required to pay a copay and/or a coinsurance. You will pay your copay and/or coinsurance until you reach your out-of-pocket maximum. Be aware, your out-of-pocket maximums can be high, sometimes up to $10,000. Once you reach your out-of-pocket, the insurance company will then pay 100% of costs.
- Medicare: Typically with Medicare, you have a $147 deductible. With Original Medicare, they pay 80% and you pay 20%. Most people choose a secondary insurance to cover the 20%. With Medicare, you will need a prescription for therapy.
- Medicare Advantage: The Medicare Advantage plans typically fall into one of the above categories. If you choose one of these plans instead of the Original Medicare plan, you may pay more per month. With a Medicare Advantage plan, you typically must choose from a list of participating providers. As with Medicare Original, you will need a prescription for therapy with a Medicare Advantage plan. For more information on Medicare Advantage plans, visit Medicare.org.
So, as stated above, not all plans require a referral to therapy, but they will typically require a prescription. With all plans, it is beneficial to have a prescription for therapy because it’s your letter of medical necessity. Occasionally, some plans will allow you 10 therapy visits before they start asking for a prescription.