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Understanding Your Insurance

Understanding insurance coverage can be challenging and frustrating, but it doesn't have to be! Let us help you navigate your insurance and explain some lingo that is used in the insurance world!



This is an amount set by your insurance company that you must pay, out of pocket, before your insurance begins to pay on a claim submitted by your doctor. This will range drastically between insurance policies, so it's good to know how much you will be paying upfront before you start reaping the benefits of your policy. For example, if your deductible is $1,000, you are responsible for 100% of the payments until that $1,000 is met. Once your deductible is met, you want to look at your insurance-to-patient responsibility ratio. As an example, Medicare covers 80% (once the deductible has been met), which means the patient is responsible for the remaining 20%. If an office visit is $100, Medicare covers $80, and the patient is responsible for the remaining $20.

Co-pay vs. Co-insurance:

Copay is the amount that you will pay per visit at the time a service is rendered. This amount is a predetermined rate that is set by your insurance company.

Co-insurance (often also referred to as cost-share) is a percentage of the charge for services rendered, and the remaining percentage is covered by your health insurance. As mentioned above in the medicare example, if your plan covers 80%, you will be responsible for the remaining 20% co-insurance.

Out of Pocket Max/Catastrophic Cap:

This is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. However, the out of pocket max does not include your monthly premiums.


This is essentially a decision by your health insurance of whether they believe a healthcare service is medically necessary. Depending on your plan, your health insurance may require pre-authorization (sometimes referred to prior authorization, pre-certification, or prior approval) before any services can be rendered.

Policy Dates

This is when your coverage, deductibles, and out of pocket max begin, as well as reset for the year. Most insurances start on January 1 and end on December 31st of the same year; however some insurances have different start and end dates.

Secondary Insurance

A lot of people choose to have secondary insurance coverage. This can come in handy, because in most cases, they pick up a lot of what your primary insurance doesn't cover. This can leave you with smaller out of pocket costs.

Why don't you take my insurance?

That's actually a fairly simple answer. When an office becomes "in-network" with with a specific insurance company, the office is agreeing to accept the payment adjustments the insurance company make on the claims. For example: Our office may bill insurance for $100 but the insurance company only agrees to pay $20. In our office, we spend so much one-on-one time with our patients that reimbursement needs to be higher. Most insurance companies list their "fee schedules" or how much they pay for certain codes. This allows an office to determine if being in-network with a particular insurance is feasible for their practice.

What if you are out of network with my insurance? 

Majority of insurance plans have out-of-network benefits. In these cases, typically the benefits are at a slightly higher rate, but it's always worth to check and see what your plan offers! In the case that your insurance doesn't offer out-of-network benefits, or it's simply too expensive, our office offers a feasible self-pay option so you can still get the care you need.

As always, the staff at RPT is here to help and answer any questions you may have. Always feel free to give us a call or ask in the office if you're ever confused about your policy or coverage!


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