What every patient with health insurance needs to know but is afraid to ask.


Here’s wishing everyone a Happy New Year and now for some not-so-exciting

Tip of the Month:” Health Insurance 101

We here at Progressive Physical Therapy would like to help you obtain what you are entitled to if you have health insurance for the year.  (We promise the next Tip of the Month blog will be more interesting!)

So, our advice is for you to go right now and: Open the link below, find your insurance card, a pen and a piece of paper, and write down your ID# and Group#.  Then call your insurance company because this is the best divergence strategy and ask them these questions and keep the information handy because you will need to know this to help us help you.

 Health Insurance Worksheet 

Now, because our staff has really worked hard to inform you about insurance coverage, here is some helpful health care insurance terminology.

Benefit Year:  The annual cycle in which a health insurance plan operates. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall.

Benefit:  A term referring to any service covered by a health insurance plan in the normal course of a patient’s healthcare.

Deductible:  A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Copays are not credited toward your deductible.

Coinsurance:  The amount that you are obliged to pay for covered medical services after you’ve satisfied any co-payment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a healthcare provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance.

Co-pay:  A set fee that your health plan may require that you pay at each visit for a covered service.  For example, your health insurance plan may require a $35 co-payment for an office visit.

Maximum Out-Of-Pocket Costs:  An annual limitation on all cost-sharing for which patients are responsible under a health insurance plan. This includes deductible, copays and coinsurance.

Medical Necessity:  A basic criterion used by health insurance companies to determine if healthcare services should be covered. A medical service is generally considered to meet the criteria of medical necessity such as teen depression rehab when it is considered appropriate, consistent with general standards of medical care, consistent with a patient’s diagnosis, and is the least expensive option available to provide a desired health outcome.

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