What does Deductible, Co-Insurance, Out of Pocket, and Visit Limit mean?

November 3, 2020 – Sometimes it is hard to believe that it is November already. Other times 2020 has been so trying for so many people for so many reasons that it has felt like the longest year that they can remember. Regardless of how 2020 has felt to us it does not change the fact that for many of us our deductibles and insurance plans are getting ready to end on December 31 and then start back over on January 1. One of the most confusing parts of our healthcare system is how insurance plans work. There are different plans for each person from different insurance companies that cover healthcare costs at different rates. Even as a provider it can be tough to keep up with all the information. Let us cover some basics today.

First you must meet your DEDUCTIBLE. This is the amount that your insurance company sets forth in your insurance contract that must be paid before they will start to help to cover any healthcare costs. This amount tends to be from $500 to $5000 per year and even that amount can be different. How fast you can meet your deductible depends on how much you use your insurance coverage and how they will pay for your healthcare usage. Some plans pay by the day and some by the procedure. Often these amounts are set by the insurance company and not the healthcare provider, but you can always call and shop around for the best situation for your plan.

Once you have met your deductible then you start to look at your CO-INSURANCE. Your co-insurance is the first sign that your insurance company will start to pay for some of your medical expenses. You have met their contracted deductible amount and now they will start to help pay for some of your medical bills. Typically, your co-insurance will be 80%/20%. This means that they will pay 80% of the bill for your services and you will pay 20%. Both payments are directed at the provider that performed and billed for those services. Co-insurances can range from 90%/10% to 50%/50%.

Now that you are using your co-insurance you need to start to understand what your MAXIMUM OUT OF POCKET is. This tends to be double your deductible amount. No matter what the number is it is again set up by your insurance company. Once your have paid the amount equal to your maximum out of pocket then your insurance company will cover your healthcare costs at 100%. This means you will not owe any more for the rest of the year. Of course, this is only true if you still follow their rules. They will not pay for anything they normally do not cover.

When it comes to physical therapy, we also need to be aware of what your visit limit is for the year. If you use all your visits, then your insurance company will not pay for any extra costs no matter what your deductible or out of pocket met amount is. Physical therapy visits can be as little as 20 visits per year or as large as unlimited. Again, these limits are set by your insurance company.

At Witte Physical Therapy we want to make sure that you are aware of what your benefits are and what your costs may be. We will provide any education needed to our current, future, or perspective patients to make sure that you understand how your insurance works and how physical therapy will be processed by your insurance company. Please contact us at 402-234-3333 in Louisville or 402-298-4747 in Plattsmouth to get any of your insurance questions answered!