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Insurance, the Scary Monster Under the Bed!


For many families, navigating the health insurance world can be a scary unfamiliar process. Many people don’t understand insurance terms and how medical appointments can affect the family financially. Hopefully these tips will help you feel more comfortable when checking into your insurance benefits and help you avoid receiving a large bill you aren’t expecting and can’t afford.

  •  It is always a good idea to check your benefits yourself when receiving a new medical procedure. Not all doctor’s offices will check on this for you. Plus, it is always good to double check because often times different reps will give different information. This is just the sad truth at all insurance companies.
  • Make sure you ask if there are any exclusions on the plan as far as what is covered. This is not information your insurance company will give without you asking. They don’t want you to know the things they won’t cover. It is not uncommon for insurance companies to exclude developmental delay, certain diagnoses like Autism or Down syndrome, and for them to have exclusions based on your child’s age. Be aware of terms like “must be medically necessary”. That means the insurance company decides what is medically necessary, not you or your doctor.
  • Find out how many visits you are allowed to have each year. Once those visits are gone, your insurance will no longer pay and you will be responsible for 100% of charges.
  • Watch your EOB’s closely! You might know those as the super annoying letters your insurance company sends you. Maybe in the past you have only cared about the large print that says “THIS IS NOT A BILL!”. These really are the only way you will know if your insurance is covering the expenses you think they should cover. Call your insurance and the provider immediately if you see a denial.

Understanding your plan:

  • Deductible: this is the amount you owe every year before your insurance covers anything.
  • Co Insurance: once you meet your deductible then your insurance will pay a certain percentage and you pay a certain percentage. Often times insurance will start to pay 70%-80% of all medical expenses.
  • Out of pocket max: This is how much you must pay out of pocket each year with your deductible and co insurance before your insurance company will pay 100% of all charges.
  • All of these amounts reset each year, so make the most of your insurance plan if you ever hit that out of pocket max!!

Hopefully with these simple tips you can start to understand your insurance plan. The knowledgeable PTC staff can help with any questions you might have and will also check into your OT, PT, and SLP benefits for you. All you have to do is ask!

Sherry Landes, Office Manager

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