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UNDERSTANDING INSURANCE + RESOURCES
This page provides a brief explanation of key terms and concepts regarding insurance and resources:
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Superbills
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Out-of-network providers
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Premera-specific resources
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HSA accounts
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Recent letter to clients about no longer contracting with insurance carriers
Superbill
For a brief overview see this description from Simple Practice.
A Superbill is essentially a receipt for behavioral health services. It allows clients to seek reimbursement from their insurance provider. It includes the date of service, service code (e.g., 90837 for a 53+ minute therapy session), diagnostic code (related to your clinical diagnosis), and the amount paid.
When you submit a Superbill to your insurance company, keep in mind that you are sharing your personal health information (PHI). If you have concerns about privacy, check with your insurance carrier to understand how they handle PHI.
Please read the following section to better understand what to expect on reimbursement.
Out-of-Network Providers
An out-of-network (OON) provider is a healthcare professional (therapist, doctor, social worker, etc.), whom does not hold a contract with your insurance carrier. OON providers are paid directly by clients or patients. They are not beholden to specific rules dictated by the insurance company, such as session time limits, service codes utilized, or diagnoses “covered”. Patients / clients can submit claims and request reimbursement after services have been rendered. The amount for which someone is reimbursed will be dependent on the carrier and the specific plan. For example, not all Premera plans have the same coverage. Each plan has a unique policy.
These are some questions you can ask your insurance carrier when exploring the option of working with an OON provider:
1. Do I have OON coverage for behavioral health?
2. What is my OON deductible? (This part is really important to clarify since many plans have a DIFFERENT OON deductible)
3. Once my deductible has been met, at what percentage does my plan cover OON behavioral health
services?
Resources Specific
for Premera Customers
Mindful Care PLLC is located in the Seattle area and thus works with many clients who have Premera BCBS as their insurance carrier. Every plan, even when under the Premera umbrella, is unique. Even plans within the same company can vary greatly. Typically employees have a variety of plans to chose from. Below I’ve compiled some helpful tips and resources specific for clients with Premera who are wanting to better understand how to utilize OON behavioral health benefits
Customer service #s:
1. for members with employer-sponsored plans: 800-722-1471
2. for members with individual plans (If you bought your plan directly from Premera or
WaHealthplanfinder.org): 800-607-0546
Plan and benefit details can be found via the Premera Member Portal
Claim submission is often most stream-lined through the Premera app.
Premera Member Submitted Claim Form for Amazon and Subsidiaries
General instructions for requesting reimbursement from Premera BCBC
Health Savings Accounts (HSAs)
A Health Savings Account (HSA) is a tax-advantaged savings account designed to help individuals pay for qualified medical expenses that their insurance may not fully cover. HSAs are often offered by employers as part of a high-deductible health plan (HDHP), and the money in these accounts can be used for a wide range of healthcare-related expenses, including behavioral health services.
How HSAs Work:
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Pre-tax Contributions: You or your employer contribute pre-tax dollars to your HSA. This can significantly reduce your taxable income while helping you set aside money for healthcare costs.
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Flexible Spending: Funds in an HSA can be used to cover co-pays, out-of-network fees, or other out-of-pocket costs for services like therapy. The money in an HSA account rolls over from year to year, so you don’t have to worry about losing it if you don’t use it within a given period.
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Debit Card Access: Most HSAs come with a debit card that allows you to pay for qualified medical expenses directly, without needing to be reimbursed later.
Using HSAs for Behavioral Health:
If your HSA covers behavioral health services, you can use it to pay your therapist directly. Simply provide your HSA debit card information, and your therapist will charge it in the same way they would any other debit or credit card. Your therapist can also provide you with a receipt if needed for your HSA records.
It’s important to review your company’s HSA policy or speak with your benefits manager to ensure that therapy and other behavioral health services are eligible expenses under your plan.
Pro Tip: HSAs are different from Flexible Spending Accounts (FSAs) and Health Reimbursement Arrangements (HRAs). While HSAs allow for funds to roll over year after year, FSAs typically have a "use-it-or-lose-it" rule. Understanding the differences can help you make the most of your healthcare spending options
For a brief guide to understanding HSA, FSA, and HRA click HERE.
LETTER TO CURRENT CLIENTS
I will not be contracting as in-network provider with any insurance company. This is a decision I have not made lightly, but one thoughtfully guided by my personal values, and my ethics as a licensed therapist. Reading this letter it’s likely you have many questions. Below I offer you the basic facts up-front and then walk you through common questions and answers.
Clients are required to pay my full session fee at the time of service:
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$170 for on-going 50 minute individual sessions
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$230 for 80 minute individual sessions
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$200 for on-going 50 minute couple/ family sessions
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$250 for 90 minute couple/ family sessions
There are both benefits and challenges to seeing an out-of-network provider. First and foremost it removes a third party from having any say in your therapy services. It allows you and I, together, to make autonomous decisions about what type of therapy you receive, how long your sessions are, and the duration you wish to stay in therapy. Importantly, no longer contracting with insurance companies allows me to better ensure your privacy. Diagnosis information, notes from our meetings, and treatment plans are no longer readily accessible to your insurance carrier. Should we decide together that a formal “diagnosis” doesn’t serve you, I’ll no longer be required to give you one. This is especially relevant for those of you seeing me for issues related to relationship counseling or grief and loss (both common human conditions that don’t meet criteria for a “diagnosis”). I’m hopeful you and I will get to continue our work together with an enhanced sense of privacy, flexibility, and autonomy.
While there are many benefits to removing a health insurance company from our therapeutic relationship, I want to acknowledge the financial impact this may have on you. I’ve developed a list of FAQs below that will hopefully answer your most pressing questions. Please keep in mind that this change isn’t happening for a number of months, so we both have time to come up with a plan moving forward that will best suit your needs.
Though I cannot anticipate every possible outcome, I have identified what you may expect when working with an out-of-network provider:
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You cover the cost of therapy yourself, submit a receipt (Superbill) to your insurance carrier, ask for reimbursement, and get a portion of the fee covered.
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Your employer provides an HSA or flexible spending account which you can use to cover the cost of therapy services.
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You cover the cost of therapy yourself, submit a receipt (Superbill) to your insurance carrier, ask for reimbursement, and due to your specific plan your insurance carrier does not reimburse you, or only reimburses you for a small amount.
FAQ
1. What exactly does it mean that you’ve “ended your contract” with my insurance?
This means I am no longer an in-network provider and am now considered an out-of-network provider.
2. Can I use my out-of-network benefits?
Yes! My choice to no longer contract with insurance does not mean you cannot utilize your out-of-network benefits. I would encourage you to call your insurance company and ask them the following questions:
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Do I have out-of-network coverage for behavioral health?
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What is my out-of-network deductible? (This part is really important to clarify since many plans have a DIFFERENT out-of-network deductible)
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Once my deductible has been met, at what percentage does my plan cover out of network behavioral health services? How much of Lina's fee will you cover?
3. Is there a way you, my therapist, can help me get reimbursed by my insurance carrier?
Yes. I am able to generate a special “receipt” called a Superbill, which you can then submit to your insurance company for reimbursement. Please note that included on this form will be a diagnosis.
4. Now that insurance isn’t paying you directly, how will we handle billing?
I keep a credit card on file for all clients, and unless we make other arrangements, my automated system will charge your card the evening after our sessions. You’ll be charged my full fee the day we meet.
5. Once I submit a claim to my insurance company, when and how will I get a reimbursement?
The answer to this question will vary depending on your carrier’s policies. Typically the insurance company will mail you a physical check. As a general policy on my end, I do not accept payment from insurance companies directly when I am out-of-network. Typically there is an option when you are submitting a claim that lets you select “send payment to customer”. I’m happy to help troubleshoot this process with you!
6. I can’t afford to keep seeing you if I’m now responsible for paying your full fee up front. What are my options?
If you do not have out-of-network coverage, or paying my full fee is not an option for you, and prompts you to consider terminating therapy prematurely please talk to me directly. The plan we come up with will be individual to your needs, but here are some likely options:
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You and I agree to a reduced fee for a limited period of time.
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You and I spend the next few months thoughtfully transitioning you to another therapist who is in-network with your insurance company.
Again, I understand that paying for therapy services directly emphasizes the commitment and investment you have to yourself. I invite this change in my practice as an opportunity for you and me to clarify and reinforce therapy goals to ensure your time with me feels as valuable and useful as possible.
Please let me know if you have further questions or want help problem solving what this change will mean for you. I’m glad to e-mail on this topic, talk during our next session, or set up a time for a phone call.
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Good Faith Estimate
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a Good Faith Estimate of expected charges.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. If you receive a bill that is at least $400 more that your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
DISCLAIMER: The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises
Please let me know if you have further questions or want help problem solving what this change will mean for you. I’m glad to e-mail on this topic, talk during our next session, or set up a time for a phone call.
With kind regards,
Elina Kogan, LSW, MFT
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