Our GTS team is here to answer any questions you have. Please email our Practice Manager, Debbie Carnesecchi, at Debbie@gatewaytosolutions.org to schedule a 15-minute insurance review call.
What kind of insurance should I choose to work with GTS during open enrollment?
We know insurance can be tricky and challenging to understand. Complex insurance terminology such as deductibles, out-of-pocket, maximum allowed amounts, co-insurance, provider networks, PPO, EPO, HMO, fee schedules, limitations, restrictions, etc., can be scary and frustrating when unfamiliar with the insurance world. Often, our clients reach out to us to help them find the best health insurance plan that works in their best financial interest to work with us.
At GTS, we help you navigate these factors and answer any questions to clarify your coverage. We require an insurance verification and benefit review phone call to fully disclose your benefits before confirming an appointment.
Some key terms to be aware of:
Out-of-Network (OON): OON providers do not have a contracted agreement with the insurance carrier. However, if your plan has OON benefits, the provider can accept those benefits, and a reimbursement will be issued based on the plan’s benefit structure. Often, the insurance carrier has restrictions and requirements for providers to remain in an insurance provider’s network that can alter and limit a client’s care plan. There is many more provider options to find that best fit your needs.
Deductibles are the amount of money a policyholder must pay out of pocket for services before their insurance starts to cover a percentage of the costs. The deductible accumulates over a calendar or contract year.
Co-insurance: After meeting the deductible, co-insurance applies. This percentage is the amount the carrier will reimburse based on the policy’s fee schedule.
Private Pay Fee Schedule: A list of prices a healthcare provider charges for services rendered to clients who pay out of pocket, whether to meet their deductible or self-pay.
Balance Payment: The amount a client is responsible for paying the provider after their insurance carrier’s reimbursement.
Courtesy Billing: In the behavioral health field, this method can relieve some of the administrative burden for clients dealing with anxiety, depression, or other mental health challenges. If a provider offers courtesy billing, the provider will file your claims on your behalf.
So, how do you select the right plan?
The first thing to consider is that the policy must have out-of-network benefits. We are an out-of-network mental health provider.
If your options have out-of-network coverage, here are things that would MOST financially help offset our private pay fee schedule:
- We recommend a low deductible of less than $3000. The lower the deductible, the faster the insurance starts reimbursing.
- The higher the co-insurance, the more the insurance will reimburse. For example,the policy will state 70% / 30% co-insurance (can be any percentage). The higher number is what the insurance reimburses. For example, reimbursement is 70% of the insurance carrier’s fee schedule. Preferably, find a plan with 70%, 80%, or 90% out-of-network co-insurance.
HMO, EPO, Medicaid, Medicare plans, or policies from the NYS Marketplace do not offer out-of-network benefits, which means the carrier does not reimburse.
If the plan offers HSA or FSA, it is a great way to put aside funds pre-taxed for healthcare expenses:
A Health Savings Account (HSA) is a tax-advantaged savings account designed to help individuals save for qualified medical expenses. Contributions to an HSA are made with pre-tax dollars, meaning they reduce your taxable income. Both employees and employers can make contributions. To qualify for an HSA, you must be enrolled in a high-deductible health plan (HDHP).
A Flexible Spending Account (FSA, also called a “flexible spending arrangement”) is a tax-advantaged financial account that allows employees to set aside pre-tax earnings to pay for eligible healthcare expenses. Money contributed to an FSA is deducted from your paycheck before taxes are applied, which can lower your taxable income.
Once your new plan is active, we will be more than happy to verify your insurance using our insurance verification form. We can verify your benefits and how they apply to you and Gateway to Solutions.
Our GTS team is here to answer any questions you have. Please email our Practice Manager, Debbie Carnesecchi, at Debbie@gatewaytosolutions.org to schedule a 15-minute insurance review call.
