February 5, 2020

Deductibles, Copayments, and Coinsurance … Oh My

Determining what you will pay for pediatric therapy

Health insurance is meant to cover the costs of your medical bills. It’s a simple concept that is anything but simple. There are so many plans out there, and each one covers different services.

However, most insurance plans include some sort of cost-sharing or “out-of-pocket” elements like deductibles, copayments, and coinsurance. How do these components work, and how can you calculate how much you will pay for your out-of-pocket expenses? Also, how do they relate to pediatric therapy for children with developmental issues?

We look at the basics of insurance deductibles, copays, and coinsurance, and how they affect what you can expect to pay for your child’s therapy.

What is a deductible?

A deductible is the amount you pay for medical services before your insurance begins to cover the costs. This amount varies widely among plans, even from the same insurance provider. Your deductible could be $1,000, $5,000 or more. Typically, a lower deductible comes with a higher monthly premium.

There is usually an individual deductible and a family deductible that includes everyone on the plan, such as your dependent children.

What is a copayment?

A copayment is the fixed amount you pay for each medical service or visit. Copays are typically applied for doctor visits, specialist visits, urgent care, some diagnostic tests, prescription medications, and more. Physical, occupational, speech, and other cognitive therapies for children generally fall under the category of specialist visits. These visits may also have copayments applied, and the cost can vary widely from plan to plan.

What is coinsurance?

Coinsurance is a fixed percentage that you must pay for each service or visit. For example, with some plans, the coinsurance amount is 20%. In that case, you would pay 20% of the cost of care, and your insurance company pays the other 80%.

One more term to learn

There’s one other term you should know about: out-of-pocket maximum.

“This is the absolute maximum you are expected to pay in cost sharing within a plan year…after your deductible has been met,” according to HealthyChildren.org.

What does your insurance cover?

As we stated, every insurance plan is different. Each will have different amounts for deductibles, copayments, and coinsurance. The out-of-pocket maximum will differ as well. Plans that are offered through an employer may have better coverage than individual plans.

The amount you pay will also depend on the type of plan, whether you have an HMO, PPO, or POS.

Plans that are part of the Health Insurance Marketplace have levels of coverage, from Platinum plans that cover 90% of medical costs on down to Bronze plans that cover 60% of medical costs.

After the passage of the Affordable Care Act (ACA), most private and public health insurance plans were required to cover pediatric therapy, including physical, occupational, speech, and cognitive therapy. Insurers also cannot deny coverage for preexisting conditions.

In addition, the Individuals with Disabilities Education Act (IDEA) requires insurance plans to provide coverage for pediatric therapy for children up to age 21 if they qualify for early intervention (Part C) or special education services (Part B).

Even so, most plans still include deductibles, copayment, and coinsurance amounts for each service. There may also be limitations regarding the number of therapy visits allowed in each period.

What is your child’s diagnosis?

It’s important to know your child’s specific diagnoses, including the formal name and the diagnostic codes. Codes are a uniform combination of letters and/or numbers that correspond to a particular disease, symptom, or service/procedure.

The codes matter because insurance will cover services for some diagnoses but won’t cover the same services for others. Once you know the codes, you can ask whether particular services are covered and/or how many visits are covered in a given period.

Resources to help you pay for pediatric therapy

Even with insurance, you may still struggle to pay for pediatric therapy. There are often state-funded health programs that can help pay for children’s medical services. Lumiere Children’s Therapy also offers membership plans with discounted rates and payment options to ease the burden of ongoing therapy.

We are also happy to help identify resources and organizations that help with medical expenses, including:

About Lumiere Children’s Therapy

Lumiere Children’s Therapy is here to provide treatment and support for children in need, education for their families, and to give hope that your child can improve and achieve traditional milestones. We strive to create experiences that help forge connections between parents and children, while also revealing the potential in each child, regardless of their skills.

Our services include:

  • Speech therapy
  • Occupational therapy
  • Developmental therapy
  • Physical therapy
  • ABA therapy (Applied Behavior Analysis for Autism Spectrum Disorder or ASD)
  • Social work
  • Augmentative alternative communication
  • Early intervention
  • Teletherapy

If your child is struggling with speech, physical impairments, or developmental delays, we can help. We will also do our best to work with your insurance and other sources of funding to provide the services your child needs.

Lumiere Children’s Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about how our team of clinicians works to improve the lives of children and their families.

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