Tips for Choosing an Insurance Plan

Whether you’re shopping for your own insurance or going through the benefits selection process with your employer, choosing the right plan can seem like an overwhelming task. While we can’t tell you which specific plan to choose, the following questions should help you with the selection process.

Questions to Ask Potential Insurance Carriers

What is my premium?

This is the monthly amount you pay for coverage. The lower it is, the higher your deductible will typically be. Plans with low premiums and high deductibles often are called “catastrophic” plans. Conversely, higher premium plans often feature lower deductibles, copays, and coinsurances.

What is my deductible, and what does it apply to?

This is the total amount you must pay each year before your insurance begins to pay. For example, if your deductible is $4,000, then you must pay $4,000 toward deductible-applicable services before your insurance will pay anything. Once you reach your deductible, your copay or coinsurance will apply.

What is my copay?

High co-pays are another common drawback to low-premium plans. Remember, the copay applies even after you have met your deductible, and the copay for specialist visits—including PT visits—can be as high as $80. So, if you anticipate a lot of office visits during this plan year, you will definitely want to factor the copy into your decision process.

What is my coinsurance?

As previously noted in this document, coinsurance is another version of cost-sharing. So, you’ll likely have to pay either a coinsurance or a copy. However, while co-pays are fixed amounts—and thus, are more predictable—coinsurances are percentages. Therefore, your financial responsibility varies based on how much your provider charges for the services rendered.

Are there any restrictions on the types of providers I can see?

Some insurance plans (e.g., PPOs, HMOs, and EPOs) are limited to a certain network of providers. So, make sure you have a good selection of covered providers and facilities in your area. If you travel frequently or live in a rural area, you may want to choose a plan that has no network restrictions.

Do I have to get a referral to see a specialist?

If your insurance plan requires you to obtain a referral before seeing a specialist (e.g., a physical therapist), and you fail to do so, the insurance company may deny coverage for services rendered. So, if you do not want to go through a primary care provider (e.g., your family physician) each time you want to see a specialist, make sure your plan does not require a referral (a.k.a. prescription) for specialist services.

How many visits of “X” am I allowed each year?

In this case, “X” represents a specific type of service (e.g., physical therapy, occupational therapy, or chiropractic). Some plans place a limit on the number of covered visits per year (e.g., 20 visits), while others allow for unlimited visits. If you’re athletic, have chronic joint pain, or anticipate needing a joint replacement in the near future, you may not want any restrictions on the number of rehabilitative visits allowed.

For Medicare secondary payers: Will this plan cover the entire 20% not covered by Medicare?

Medicare only pays 80% of the cost of care, so many Medicare beneficiaries seek secondary insurances to pay the other 20%. However, even those plans often feature deductibles, copays, coinsurances, or visit limitations. Thus, we recommend posing all of the above-listed questions to any secondary insurances you are considering.

The Bottom Line  

Higher-premium plans are generally better for individuals who expect to receive medical care on a regular basis. Lower premium plans will save those individuals money monthly, but those savings won’t make up for the cost-sharing portion.

The Self-Pay Option

If I don’t want to use my insurance, can I just pay for services myself?

The self-pay rate for all follow-up visits at Physical Therapy Specialists is $90. Because an insured patient with a deductible may have to pay $75 or more for the same service, many insured patients ask if we can essentially “pretend” they are uninsured. However, if we contract with your insurance company, we are obligated to honor that contract—which means we must bill your insurance for services rendered. Some contracts also prohibit us from providing discounts or waiving patient financial responsibility (e.g., copays or coinsurances). That said, if we do not contract with your insurance, or if you have exhausted your benefits for the year, then you may be eligible to receive services on a cash-pay (i.e., self-pay) basis.