Insurance Information

Insurance Information

We include a wide variety of health insurance plans which makes it easier for you to access care. Please keep in mind that insurance plan coverage often updates and changes. It is always a good idea to check with your insurance company for specific information about your benefit plan, your policy coverage limitations, and your choice of providers.

Frequently Asked Questions About Insurance:

What if I don’t see my plan? Are you in my network?

We recommend that you contact your insurance company as they will have the most current list of participating providers for your benefit plan.

Who should I contact with billing questions?

Please discuss any billing concerns with the office manager.

Do you offer payment plans?

Yes, we offer payment plans.

Can I pay my bill online?

Online bill payment is available.

Note: out of courtesy, we provide an estimated quote for physical therapy services based on the information provided when calling to verify your insurance coverage. Ultimately, it’s how your insurance provider processes the claim which determines your actual financial responsibility. Please refer to your policy and always review your explanation of benefits (EOB). You explanation of benefits should be readily available after your claims are processed.

Insurance terms glossary

Co-Pay – a flat fee paid at the time you receive a health service. For example, your insurance plan may require a $30 payment at time of your clinic visit. Some plans waive co-pays once the annual out of pocket expenses are met.

Deductible – basically, you share in the cost of your health care plan. The sharing starts with the deductible. For example, if your deductible equals $1,000, you’ll pay that amount out of pocket before the insurance company begins paying anything for your health care. Of course, you’ll continue sharing in the costs with co-pays, co-insurance and any costs not covered by your plan. Note: some plans pay for some health care services prior to you meeting your deductible.

Co-Insurance – different from co-pay, this is a fixed percentage you pay after reaching your deductible.

Co-insurance is paid after the insurance company pays their % of the cost. For example, if your policy calls for 20% co-insurance payment, the insurance company pays $80 of $100 charge and you’re responsible for paying $20. This can in addition to your co-pay if your deductible has been met.

Also, there’s the co-insurance maximum which is the most you have to pay before your insurance provider picks up 100% of the cost. Note: the co-insurance maximum most often does not apply to co-payments and other expenses you have to pay according to your plan.

Out-of-pocket maximum or limit – here’s what healthcare.gov says:

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, co-payments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

The out-of-pocket limit doesn’t include:

  • Your monthly premiums
  • Anything you spend for services your plan doesn’t cover
  • Out-of-network care and services

Preexisting condition – the Department of Health and Human Services says: “Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “preexisting condition” — that is, a health problem you had before the date that new health coverage starts.

These rules went into effect for plan years beginning on or after January 1, 2014.

Health insurers can no longer charge more or deny coverage to you or your child because of a preexisting health condition like asthma, diabetes, or cancer. They cannot limit benefits for that condition either. Once you have insurance, they can’t refuse to cover treatment for your preexisting condition.

The preexisting coverage rule does not apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family on or before March 23, 2010 that has not been changed in certain specific ways that reduce benefits or increase costs to consumers.”

Referral – when your primary care doctor refers you to a specialist or other medical services. If you don’t get a referral first, HMO’s and some insurance providers may not pay for the costs you incur.

Out of Network – according to Texas Health Care Costs , “Health care services performed by physicians or hospitals that have not agreed to provide medical care for members of a health plan at a negotiated rate. An HMO plan usually only pays for care received from within its network, and a PPO plan requires members to pay more to receive out-of-network services.”

Out-of-network – when you receive care from non-preferred providers.

Out-of-network coinsurance – Texas Health Care Costs says out of network coinsurance is  “The percent you pay of the allowed amount for covered health care services to doctors and hospitals that do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network coinsurance.”

Out-of-network co-payment – when you use a healthcare provider that doesn’t contract with your insurance provider, you pay a fixed amount  for covered health care services. 

Out-of-network services – health care services from healthcare providers who are not your HMO, PPO, or EPO. In general, HMO’s and EPO’s only pay for services within their networks. PPO network members have to pay more for healthcare service outside the network.

More insurance terms

Allowed amount – the maximum your insurer pays for a covered service. If your healthcare provider bills you for more than the maximum amount, the remaining balance will be adjusted off as co-45 which means contracted rate.

Balance billing – the billing for non-covered services.

Billed amount – the cost you’re billed by a healthcare provider for treatments and services you have received. If you don’t have insurance, this becomes your cost to be paid by you.

Cost Sharing – the costs you pay out of your own pocket. Texas Health Care Costs says that means “deductibles, co-insurance, and co-payments, but it doesn’t include premiums, balance billing amounts, or the cost of services that are not covered.”

Exclusions or limitations – services  your health plan doesn’t pay for or cover.

In Network – according to Texas Health Care Costs, “Health care services performed by physicians or hospitals that have agreed to provide medical care for members of a health plan at a negotiated rate. This term includes physicians or providers that are members of a Health Maintenance Organization (HMO) delivery network or a Preferred Provider Organization (PPO) preferred provider network.”

Premium – the amount you pay monthly, quarterly, or annually for your health insurance. If you participate in an employer sponsored plan (or any other sponsored plan), then your employer picks up a portion of your premium.

Preauthorization, precertification, prior authorization, prior approval – when an insurer preapproves your treatment or service. Once approved, they’re agreeing the service is medically necessary. If you receive a treatment or service without preapproval, your insurance company may not pay.

You might need approval for some services – most plans require you to get approval before some covered services. In general, this includes surgery or hospital admittance. Check with your plan. No approval means your plan might not pay.

If you have questions or need an appointment, call our River Oaks clinic at (832) 409-6390 . If you’re in the Friendswood area, call (281) 482-7380.