Common Insurance Terms

Calendar Year Maximum—Many benefit plans allow a certain amount of mental health visits each calendar year. If you go beyond this number, the plan will not pay but consider you responsible for those charges. We make every effort to keep track of your calendar year maximum, but you are responsible for monitoring this by conferring with your insurance company, by informing us of any visits with other counselors that might count toward your allowed number of visits per year, and by paying for any visits beyond your calendar max.

Coinsurance—This is the amount of payment that the patient is responsible for. It is based on a percentage of what the insurance company allows for a mental health session. Your co-insurance amount may be different for a mental health visit, compared to a visit at your doctor’s office. With most plans, if you are responsible for a coinsurance, you are not also responsible for a co-pay in addition to that.

Co-pay—This is a specific dollar amount that the patient or responsible party must bring to each session. The co-pay amount does not change unless changes are made to your bene­fit plan by you, your employer, or your insurance company. Your co-pay amount may be different for a mental health visit compared to a visit at your doctor’s office. With most plans, if you are responsible for a co-pay at each session, you are not also responsible for a co-insurance in addition to that.

Covered Services/ Non-Covered Services—There are services covered or approved for payment by your insurance. Certain procedures or types of treatment are not allowed under certain plans. Sometimes a policy covers medical expenses, but does not have coverage (i.e., they will not pay) for mental health services.

 

Deductible—Most insurance plans have an individual or family deductible that must be met by you before the insurance company will start paying towards your benefi­ts. This means that they will not start paying until you have paid a certain amount “out of pocket.” The deductible has to be met anew each year. Typically, the insurance company applies your medical expenses, prescriptions, and mental health expenses toward this deductible. Until your deductible is met, you are responsible for paying the full allowed amount for your sessions with us at Encompass Counseling Center.

Employee Assistance Program (EAP)—Some employers offer a special yearly benefi­t to employees that provides a specifi­c number of mental health visits paid in full by the employer, with no cost to the patient. An EAP pays for the number of visits (2-8, depending on the plan), is often available for each family member, and is separate from the mental health benefi­ts in the medical plan.

Explanation of Bene­fits (EOB)—This is the paperwork which details how the insurance company processes a claim submitted for a speci­fic date of service. The EOB details how much is allowed by the insurance company for each session; if insurance is applied towards your deductible; how much the insurance company is paying toward your claim; and, the amount deemed by the insurance company to be the patient’s responsibility. Anytime the insurance company sends Encompass Counseling Center an EOB, it also sends one to you.

Insured—The insuredis the person whose name the policy is under. Even if a child or spouse is covered under the insured person’s insurance plan, and is coming as the patient, the insured’sname, address, and date of birth are needed for the insurance company to pay your claim.