Going out of network? What you need to know

Is your caregiver out of network? Frequently postpartum depression specialists are. Here are some helpful definitions.

First you’ll need to understand what your coverage is for out of network expenses. Some insurance plans don’t offer out of network support at all. Many do though.

When reviewing your plan, you’ll see words like “deductible”, “coinsurance”, “out of pocket maximum”, “allowed benefit”. Let’s define those.

A deductible is the up front cost that you, the patient covers, before the insurance company steps in. With that, it’s important to understand that only allowed benefits are contributed to the deductible amount. So…what is the allowed benefit?

The allowed benefit is the amount that the insurance company values/is willing to pay for the particular service. For example, if my caregiver charges me $150 per therapy session, and my insurance allows $100 of that cost, that $100 is the allowed benefit. As discussed with the deductible, that $100 goes toward the total deductible pot – not the $150. You have to pay the $50 – that’s called balanced billing.

Coinsurance refers to your responsibility of the allowed benefit. If your coinsurance is 20%, then the insurance company will pay 80% of the allowed benefit.

Finally there is an out of pocket maximum. The Affordable Care Act requires insurance companies to apply deductibles, coinsurance and copays against the out of pocket maximum. So the allowed benefit amount goes toward whatever that maximum is. Once that maximum is achieved, you don’t pay any of the allowed benefit.

For more information, these sites are particularly helpful:

Talk to your HR representative to understand your plan and what it offers. Additionally, your company may have other benefits such as Health Advocate, which is a service that helps people navigate the ins and outs of health insurance. They can coordinate with huge insurance companies to get questions answered and will sit on calls with you to get to the bottom of the issue. If you’ve got a Flexible Spending Account (FSA), check and see if mental health therapy is on the list of covered expenses.

More importantly, get your partner involved. If you’ve got postpartum depression, you may feel drained and not have the energy to sort out filing claims. It took me months to work up the effort to do so. Your partner can help with research, fill out forms, sit on the phone with the insurance company to get answers.

Lastly, break it down into tiny steps. Do one thing a day, or one thing every two days. It’ll help make things feel less insurmountable as you chip away at your list of things to do. If you’ve got a friend or confidant, have them help hold you accountable to make progress towards getting well and getting reimbursed.

Postpartum World_ICON_4C_Green Rattle

Disclaimer: I am not a health insurance expert. I simply am relaying my experience with getting money back from my own insurance company while working with out of network specialists. Please talk to your healthcare provider or HR department to understand the intricacies of your own plan.

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