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Serving Westchester, Rockland, Putnam Counties and beyond
Hudson Valley Logo
Serving Westchester, Rockland, Putnam Counties and beyond

A New Year is upon us and with that a new benefit period for most inusrance plans. My cousin, Paul Vidal, who is also a Physical Therapist (must run in the family!) and owner of Specialized Physical Therapy LLC in South New Jersey, recently posted definitions of insurance terminology. I thought it would be helpful for you to learn what all these words really mean. It is confusing enough to figure out what your insurance plan does and does not cover. Add to that the lingo the insurance companies use and you have yourself one big headache! So here it goes….

Allowed Amount – The amount an insurance company will cover (pay) for a service.

Benefit Period – When services are covered under your plan. It also defines the time when benefit maximums, dedcutibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans. Example: you may have a plan with a benefit period of January 1 through December 31 that covers 30 physical therapy visits. This 31st or more session will not be covered.

Coinsurance – A certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. Example: Your plan might cover 80% of your medical bill. You will have to pay the other 20%. The 20% is the coinsurance.

Coinsurance Limit(or Maximum): The most you will pay in coninsurance costs during a benefit period.

Copayment (Copay) – the amount you pay to a healthcare provider at the time you receive your services. You may have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay.

Covered Charges: Charges for covered services that your health plan paid for. There may be a limit on covered charges if you receive services from providers outside your plan’s network of poroviders.

Covered Service – A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for htese services based on your plan.

Deductible – The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time). Example: If your plan has a $2,000.00 deductible, you will be expected to pay the first $2,000.00 toward your healthcare services. After you reach $2,000.00, your nsuracne company will pay for services. You kmay still have a coinsurance depending on your plan.

Medically Necessary (or Medical Necessity) – Serivces, supplies or prescription drugs that are needed to diagnose or treat a medical condition.

Medicare – A federal program for people age 65 or older that pays for certain healthcare expenses. There is a yearly deductible has to be paid by each individual with Medicare (in 2018, it is $183.00), before Medicare will pay for services.

Network/ In-network Provider – A healthcare provider who is part of your insurance plan’s network. When a healthcare provider is part or your insurance plan, you will hear “they are in-netowrk or they are participating provider”.

Non-covered Charges – Charges for services and supplies that are not covered under the health plan.

Non-network / Out-of-Network Provider – A healthcare provider who is not part of your insurance plan’s network. The provider does not have a contract with your insurance plan.

Out of Pocket Cost – Cost you must pay. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket(MOOP) cost. Consult your plan for more information.

There is also a difference between HMO and insurance plans. HMO plans do not include out-of-network benefits. PPO plans include out-of-network benefits. They will help pay for the care you get from providers who do not participate with your plan.

Due to the specialized nature of our physical therapy services and the time spent with our patients, Hudson Valley Physical Therapy is an out-of-network provider. As a courtesy, we will verify your out-of-network benefits prior to your first visit. See our Financial Polices information on our website. Please call us if you have further questions regarding your insurance coverage, 914-831-9575.

We wish you all a Happy and Healthy New Year!

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