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Understanding Your Health Insurance Benefits

What is a deductible?
A deductible is the amount of money you must pay for covered healthcare services before your insurance starts to pay anything (except for certain preventive services). For example, a health insurance plan with a $1,500 individual deductible means you will pay the first $1,500 of costs for covered services yourself.

Your plan may also have a family deductible that applies to all family members insured by the plan. For example, a health insurance plan with a $5,000 family deductible means your family must spend $5,000 on health services before your health insurer will pay anything.
An individual within a family may hit their individual deductible before the family meets the family deductible. In this case, the insurance plan will begin to pay for that individual family member, but other family members will still pay the full cost of services until the family deductible is met.

Once the deductible is met, you will usually owe a copayment or coinsurance, and your insurance plan will pay the rest.

Note: Your plan may have separate in-network and out-of-network deductibles.

What does it mean for a service to be in-network?
Your insurance network has contracted with certain providers to give care to individuals enrolled in their plans. For a list of providers who are in-network with your insurance plan, contact your insurance provider.

What does it mean to obtain services from an out-of-network provider?
Certain insurance plans allow members to obtain services from providers who are out of their network. However, visiting an out-of-network provider may include a higher fee and a separate deductible.

Depending on your benefits, your insurer may reimburse you part or all of the paid costs of service.

What is a copayment/coinsurance?
These are payments you make each time you have a covered medical service after meeting your deductible (until you meet your out-of-pocket maximum, as discussed below).

Copayments are flat-rate payments (for example, you may pay $30 for a doctorโ€™s visit).

Coinsurance is a percentage of the service fee which you are responsible for paying. For example, for a doctor’s appointment with a fee of $125.50, with a 20% coinsurance, you would pay $25.10 for this service.

What is my out-of-pocket maximum?
Your out-of-pocket maximum is the most you have to spend on covered healthcare services in a year. After you spend this amount on deductibles, copayments, and coinsurance for covered in-network healthcare services, your health insurance will pay for 100% of the costs of covered benefits for the rest of the plan year.

What is preauthorization and how do I know if this applies to my health insurance plan?
Certain health insurance plans require prior authorization for certain treatments. Since coverage will not be authorized without it, beginning the prior authorization process early is important. It is recommended you contact your insurance company to determine if you need prior authorization before initiating mental health services at Light On Anxiety.

To get the most accurate information, we recommend contacting your insurance company directly, as benefits and financial responsibility may vary depending on plan type. It may be helpful to provide your insurance company with the information below to expedite the process of them informing you of your financial responsibility for treatment at LOA:

Therapy CPT/Billing Codes:
90791 for intake
90834 for 45 min session
90837 for 60 min session

Medication Management CPT/Billing Codes:
90792 or 99205 for intake
99212, 99213, 99214, or 99215 for follow-up appointments

NPI for Light On Anxiety: 1619308087

Your insurance company may also ask for the diagnosis code for your treatment service. See the list below for the most frequent conditions we treat and the associated diagnosis codes.

Sample Diagnosis Codes:
Generalized Anxiety Disorder F 41.1
Panic Disorder F 41.0
Obsessive Compulsive Disorder F 42.9
Social Anxiety Disorder F 40.10
Specific Phobias F 40.2
Trichotillomania F 63.3
Skin Picking F 42.4
Depression F 33