How insurance works

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What Is a copay? 

A copay is a fixed cost per service. If a plan states that the mental health benefits are subject to a copay, sessions will cost the same, regardless of the CPT code(s) billed.

 

What Is a deductible?

A deductible is a set amount of money one must pay before insurance begins to pay for care. Plans can have an individual deductible (must be met by the individual seeking care) or a family deductible (if applicable). Deductibles typically reset on a yearly basis.

Deductible not met
Sessions are billed at the full session rate (set by insurance), and will vary depending on the CPT code(s) used. While paying the full rate with insurance may seem non beneficial, using insurance allows a) possible lower costs relative to out-of-network and b) contribution to the overall deductible alongside other healthcare expenses.
Deductible met
Insurance will cover a percentage of each session cost, depending on the individual plan. The percentage left over is called “coinsurance.”

 

What Is coinsurance?

Coinsurance is the percentage of the total session cost due to Headway, after the plan deductible has been met (the insurance company will cover the remaining percentage). For example: the plan details indicate a $1000 deductible [met] and a client responsibility of 20% coinsurance. Therefore, the amount owed will be 20% of the session rate, and insurance will cover the remaining 80%.

 

What Is an out-of-pocket maximum?

An out-of-pocket maximum is the capped amount that one will spend from their own ‘pocket’ in a given year. Once reached, clients will not be responsible for any additional costs. This maximum amount is met through the accumulation of client responsibilities paid, after the insurance company has covered their share.

 

How are session costs determined?

Pricing is calculated based on current plan details on file. The expected session cost (based on average session type and length) will be displayed to both the client and the provider within the respective accounts, as well as in appointment reminder emails. If session costs do not align with expectations, submit an inquiry using our contact form so that we can further verify. Be sure to include the front and back images of the insurance card.

 

What If the Insurance Details Cannot Be Verified?

If you see a notice that there’s a problem with the insurance as entered, it means that we may need to reach out to the insurance payer directly to obtain benefit details and eligibility. Double-check that the date of birth, legal name, and member ID match exactly to the insurance records. If still unverified, you can submit an inquiry by completing via the following process.

Client
When an error message appears on your Account page stating that we could not verify your insurance information, click “Verify benefits” and fill out the form.
Provider
When a client’s insurance needs verification, this will be indicated by their name on your Clients tab in Sigmund. You can then request the insurance verification through Sigmund as well by clicking on the “Verify benefits” button and filling out the form.

Getting all of the pertinent information this way will help us respond to as soon as we can! Please note that until insurance is verified, sessions will need to be placed on-hold (or held off of the Headway platform), as sessions cannot be billed nor claims submitted until resolved.

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