Allowed/Contracted Amount: The highest rate an insurance plan will cover (pay to the service provider) for services. This varies by insurance company. 

Benefit period: This is typically January 1st through December 31st, but not always! This is the period in which services are covered. This also dictates the period in which deductibles, out of pocket maximums, and session limitations are accrued. For example, you may have reached your deductible for the year, but you should plan on that being reset come January 1 of the following year. Contact your insurance provider directly if you are unsure if your plan follows the calendar year period.

Coinsurance: The amount you have to pay for every covered service after your deductible has been met. For example, if you have 80% coinsurance, you are responsible for 20% of every $1 spent. On occasion, plans will have a coinsurance and a copayment (see below), though this is rare. For those plans, you are responsible for the copayment and coinsurance cost. 

Copayment: The amount you have to pay for every service received. Often, copayments apply even before you meet your deductible. An important note: oftentimes, copayments differ between different services. For example, your copayment for outpatient behavioral health services (us) might be different from a primary care visit. Some plans have different rates for specialists (specific service providers as defined by the plan) as well.

Covered Person: Anyone covered under your insurance plan. For example, those in a marital relationship or covered under domestic partnership will often share an insurance plan. Dependents are also typically eligible to be covered under a guardian’s plan up until their 26th birthday.

Covered Service: A service or product covered under your insurance plan. Do note that just because a service is covered, doesn’t necessarily mean insurance will pay it out right. If you have a deductible, for example, a covered service is applied to your deductible but you have to pay the actual fee (until your deductible is met).

Deductible: The amount you are required to pay in order for your insurance policy to pay/reimburse for services, typically within a calendar year. This is often associated with coinsurance (see below). For example, if you have a deductible of $1,500 with coinsurance of 80%, you will have to pay for services (with any provider within the insurance network) up to $1,500, at which point your plan will cover 80% of every $1 spent. Note that everything covered in your insurance plan counts towards your deductible and that there is no distinction between mental health and physical health accumulations. 

FSA/HRA/HSA: These are all types of healthcare spending accounts that can be set up with employers. These accounts often take money out of your paychecks, pre-taxed, to be used for healthcare expenses. LSW can typically charge these accounts, but specific details must be worked out with employers.

HMO: Health Maintenance Organization (HMO) is another type of insurance plan that will, typically, require its policy holders to choose a primary care doctor, who will often need to provide referrals for other HMO providers in order for coverage to be met. Please note LSW is not in network with any HMO plans at this time although an HMO policy might cover out-of-network benefits. 

In-Network Provider: A provider that has a contract with your insurance plan. The practice AND your individual therapist need to be registered as an in-network provider to use your insurance benefits with us. There are always exceptions, which is why we try to verify benefits at the start of service.

In-Patient: Services that require an overnight stay at a facility. For example, in-patient hospitalization programs, rehabilitation facilities, nursing home stays, major surgery, and overnight hospital stays are in-patient services.

Non-Covered Charges: A service or product not covered by your insurance plan. For example, some plans will cover individual therapy, but will not cover relational/family sessions. You would need to pay the full price for these sessions, or seek out a sliding scale rate.

Out-of-Network Provider: A provider who does not have a contract with your insurance plan. Costs associated with out-of-network coverage may be higher. Our therapists can see clients with out-of-network coverage, but clients are responsible for paying the full session fees and submitting a Superbill (see below) to their insurance providers for reimbursement.

Outpatient: Services that do not require overnight stays. LSW is considered an outpatient provider.

Out of Pocket Maximum: Out of pocket expenses are anything you are paying for-you guessed it, out of pocket with your own money! This includes accruement towards deductible, copayments and coinsurance. Most plans have an out of pocket maximum that, when reached, insurance will begin paying 100%. Check with your insurance plan for specifics on the out of pocket maximum.

PPO: Preferred Provider Organization (PPO) is a type of insurance plan that offers more extensive coverage, and does not typically require referrals. These plans are often more expensive than HMO plans, but offer greater flexibility.

Premium: In simple terms, a premium is the cost of your insurance coverage.

Medical Necessity: Most insurance plans require a proven medical necessity in order for services and products to be covered. Some plans are more particular about this proof and require additional steps. For example, most City of Chicago plans require authorization in coverage before services are rendered to prove medical necessity. Check with your plan for specific details.

Superbill: An itemized list that is often used when a provider is out-of-network. It allows patients to pay upfront and then seek partial reimbursement from their insurance company by submitting the superbill and a claim form. Superbills must usually include date of service, provider and patient details, and diagnostic and procedural codes in order to be accepted by insurance providers.