Insurance 101
Deductible
A deductible is a specific amount of money that an individual must pay out of pocket for covered health services before their health insurance begins to contribute to the cost. The total amount of your deductible and what services require payment towards your deductible is determined by a client’s insurance plan.
Copay vs. Coinsurance
A copay is a set amount determined by insurance that a client pays for a specific service, typically collected at the time of service (i.e. doctor visits, prescriptions, etc.). Coinsurance is the percentage of cost determined by insurance that a client pays towards each claim after meeting their deductible. For example, a client has met their $1000 deductible and now has a 20% coinsurance, this means insurance will pay for 80% of your claim and the client is responsible for 20% of the claim.
Some plans may have a copay and coinsurance.
In-Network vs. Out-of-Network
In-network providers are those who are contracted through specific insurance companies, meaning an in-network provider “accepts” the insurance. Out-of-network providers are not contracted, meaning an out-or-network provider does NOT “accept” the insurance, so a client would have to pay out of pocket for care.
Superbill
A superbill is a type of receipt provided by your clinician’s office that an insurance company needs in order to reimburse a client for seeing an out-of-network provider or to count towards your deductible. This can also be submitted to your secondary insurance for reimbursements.
If you are covered under two different insurance plans, that means you have a primary and a secondary insurance.
Primary insurance pays first on your claims. Whatever is not covered by your primary insurance will then be billed to the secondary insurance.
*Sunstone does not bill secondary insurance*
A coordination of benefits is a process used by insurance companies to determine which of your insurances is your primary and which is your secondary.
If you are double covered, you will need a COB. Reach out to your insurance companies to double check you have this or to get the process started. This helps avoid delay in processing and inaccurate medical bills.