Insurance 101

by Emily Grobbel, Clinic Administrator
Duncan Lake Speech Therapy, LLC

Deductibles and maximums and copays – oh my!

Insurance can be a daunting topic, especially as we begin a new year, and deductibles are restarting. Here is a quick refresher on several terms you have probably encountered recently, and some tips to ensure a smooth process in navigating your policy.

Deductible vs. Out of Pocket Maximum:

A deductible is the amount that you will need to pay out of pocket before insurance starts to pay for your speech therapy sessions. Usually, this resets at the beginning of the year, meaning the cost may look a little different at the beginning vs. end of the year.

An out of pocket maximum is the maximum amount that you will pay out of your own pocket, including copays and/or coinsurance. These amounts are usually larger than deductibles. When you meet your deductible, you may still have a copay or coinsurance to pay. These go towards your out-of-pocket max. Once you reach your out-of-pocket max, your insurance will cover your visits in full for the rest of the year.

Copay vs. Coinsurance:

A copay is the set dollar amount that you pay for each office visit. This is determined by your specific plan, and can vary based on if the provider is in-network or out-of-network. This amount usually contributes to your out-of-pocket maximum. Some policies do not require a copay. If you have a copay, you likely do not have a coinsurance.

A coinsurance is a percentage of the visit cost that you are responsible for. This kicks in once you have met your deductible. For example, if you have met your deductible, and you have a 20% coinsurance, you pay 20% of the visit cost, and insurance covers the other 80%.

During the intake process, we do check with your insurance company to determine your plan’s deductible, out-of-pocket max, and copays/coinsurance as it pertains to our speech therapy services. However, it is always important for you to have a good understanding of your specific policy. If you are unsure, you can call the member services number usually found on the back of your insurance card. If you have any changes to your insurance, please let us know so we can avoid any denials for service.

We hope this refresher clears up any confusion and makes insurance a little easier to understand. As always, if you have any questions, please don’t hesitate to ask us!