By: Jennifer Golden, EBHA Billing Specialist 

Health plans can seem complicated. It helps to know what questions to ask and where to find the information you need. The following information will answer questions about deductibles, changes in insurance, and other information to help better understand the complex world of insurance.

Let’s first start with the difference between a benefit year and calendar year plan. A plan on a calendar year runs from January 1 – December 31. Items like deductibles, maximum out-of-pocket expenses, etc. will reset every January 1. A plan on a contract year runs for any 12-month period within the year. Most plans run on a calendar year.

Will my insurance be in-network? Eating and Behavioral Health Associates is in-network with Aetna, Cigna, Medical Mutual, Ohio Healthy (Optima), Humana (Commercial), First Health and Ohio Health Choice (Ohio PPO Connect). The type of insurance you have will be listed on your insurance card, but you will want to make sure your mental health benefits run through your insurance directly by checking your description of plan benefits which should include information on behavioral health services. For instance, State of Ohio employees have medical through medical Mutual of Ohio, but their mental health benefits are paid by United Healthcare.  If you still aren’t sure, ask your human resources representative or contact your insurance company directly. Additionally, you can call your insurance company or visit the company’s website for a list of in-network providers.

When using your mental health benefits for an in-network provider you will want to check with your insurance department or insurance company for specific details about your coverage. Here are some important points to consider:

  • Ask if you have a copay, deductible, co-insurance and out-of-pocket-maximum.
    • Copay – These are fixed dollar amounts you’ll pay for office visits. Your copay ends only when you have reached your out-of-pocket maximum.
    • Deductible – This is how much you must pay out-of-pocket before your health insurance starts making any payments.
    • Co-Insurance – The percentage of health care costs you’ll have to pay for care after meeting your deductible.
    • Out-of-Pocket-Maximum – This is the most you’d have to pay for covered services in one year – it includes deductible, co-insurance and copays.

Many insurance plans will have a deductible. This means you will pay the full cost of the appointment upfront until the deductible is met. Then you will pay your copay or coinsurance amount until you meet your yearly out-of-pocket maximum. Coinsurance is when your plan pays a large percentage of the cost of your appointments, and you pay the rest. For example, if your coinsurance is 90/10, you will only pay 10% of the costs of each appointment and your insurance will pay the rest.

If your insurance plan covers your family, there will most likely be an individual deductible for each person and a separate family deductible. Once your family deductible has been met, your plan will start paying your coinsurance amount for everyone’s care even if some haven’t met the individual deductible.

Some plans will have a visit limit as well. Please check with your insurance company to confirm if your plan has a limit or if it is unlimited for mental health appointments.

Telehealth coverage is important to inquire about as well. When reaching out regarding your benefits for the new year you will want to ask if Telehealth is still covered and if your copay (if you have one) is different if your appointment is in an office setting via telehealth.

If you have additional questions about your company’s plan, please reach out to your HR rep or your health plan directly with benefit questions for the new year so you are fully prepared for costs associated with your appointments.

As always, our team is happy to help with any questions you may have about your benefits.  You can reach out to our admin team at 614-431-1418.  You can also find more information on our website at: EBHA Insurance FAQ or view our online webinar.