All About Health Insurance

 

How to choose your health insurance & keep us as your providers

Discussion by Experience Momentum

 

Are my Experience Momentum providers and other healthcare providers included in my plan?

Know the name of the billing providers, which might be different than your actual provider. Contact your health insurance representative or the plan representative, or you can search online within the plan's website. For Experience Momentum providers, use the names:

  • Shanon Tysland, for Physical Therapist related services
  • Karen Hogan, for Massage Therapist related services
  • Chelsea Moore, for Nutrition / Dietitian related services

Can't find our names? Don't panic, give us a call and we will help you sort it out. Email us at insurance@experiencemomentum.com.

 

How does "In-Network" and "Out-Of-Network" affect access to my providers?

Being "In-Network" means your provider is within the plan's network and will cost you less than if your provider was "Out-Of-Network." However, you can still see "Out-Of-Network" providers. Who is "In" and who is "Out" depends on the plan. Search within the plan for our providers or Email us at insurance@experiencemomentum.com

 

Should I choose the plan based on its cost or what it provides?

We recommend considering what you need the plan to do for you in the upcoming year. Are you a frequent flyer to a Physical Therapist, Registered Dietitian, and/or a Massage Therapist? If yes, you will want to be sure that Experience Momentum providers are "In-Network" or that the plan includes "Out-Of-Network" benefits, which will be listed. Then, you will want to see how many visits are permitted within the plan and how they are allocated. Watch out for plans that combine Physical Therapists, Massage Therapists, and Chiropractors as each will tick away at your total visit count.

If you are considering having surgery or a procedure in the coming year, it is important to do the math on what your out-of-pocket maximum, deductible, and co-pays are, as this will help you plan for what you could actually end up spending in the upcoming year. 

 

What should I know about Prior-Authorization? (i.e., EviCore, Optum, etc.)

Prior-authorization has been around for a while, however recently, Physical Therapists and Massage Therapists were added to the list. Double check on whether your plan has this component. We DO NOT RECOMMEND prior-authorization as it results in the insurance companies discontinuing care against our medical advice. We are actively communicating with the legislature to try and change this for your benefit. Want to help--ask us how! Email us at insurance@experiencemomentum.com

 

What's the difference between an HMO and PPO plan?

An HMO provides access to specific healthcare providers and hospitals within the HMO's network. A network is made up of providers who have agreed to lower their rates for plan members and also meet quality standards. Care under an HMO plan is covered only if you see a provider within the HMO's network. A PPO plan enables you to see providers outside of the HMO. Experience Momentum recommends a PPO plan, as the HMO plans will not allow you to see our Doctors of Physical Therapy, Massage Therapists, or Registered Dietitians. 

 

Is there a benefit to an Individual versus a Family Plan?

An individual plan has a deductible and out of pocket maximum for both you as the policy holder and for your family. Whichever amount is met first would overrule the other. In a family plan, you have one deductible and out of pocket maximum to be met, but the amount is much higher. Ask yourself--who uses your benefits? How likely is it that you or your family will require Physical Therapy, Massage, or Registered Dietitian or other healthcare services? Are there any procedures you or your family will likely have in the coming year? 

 

What is Deductible & Out-of-Pocket Maximum?

The deductible is the amount you must pay out of pocket for medical care before the insurance company will begin paying. The out-of-pocket maximum is the most you have to pay for covered services in a plan/calendar year. After you spend this amount on deductibles, co-payments and co-insurance, your plan pays 100% of the costs of covered benefits. 

 

What's the difference between Co-Pay & Co-Insurance?

The Co-Pay is a fixed fee for types of doctor visits, prescription drugs, or other kinds of care. Knowing the health insurance copay allows you to know ahead of time exactly how much you will owe. If your policy lists a health insurance copayment of $25 for a doctor visit, you pay that amount each time you see that type of doctor. Co-Insurance is a percentage of the total cost for a covered medical service, instead of a fixed Co-Payment fee. If the insurance company owes a doctor $100 for your visit and you have a Co-Insurance percentage of 25%, you may be required to pay $25 towards the cost of that visit. The average Co-Insurance is 25% and the average Co-Pay is $30. 

 

Does it matter if I have a plan-year plan, or calendar-year plan?

If you have a calendar year plan, your benefits run from January 1st each year to December 31st. All of your deductibles, out of pocket maximums and visit limits would reset on January 1. If you have a plan year plan, your benefits would run from the month set by your employer to the same month in the following year. Your HR department can answer this question for you.

 

What is a visit limit? Does that mean I get all of those visits?

The visit limit is the maximum number of visits you can be seen for a covered service each year. Of note, it does not matter if you meet your out of pocket maximum for the year--if you have used all of your visits you will not be allotted additional, so be mindful of how many visits you have for Physical Therapy, Massage, and Registered Dietitian care. Experience Momentum recommends plans that allow >40 visits per year. However, just because you have 40 visits covered for a service does not mean you can use all of them--prior authorization and medical necessity for the service will ultimately determine how many of your visits you are able to utilize.

 

Should I choose a high or low-deductible plan?

High deductible health insurance plans typically cost less than traditionally lower deductible coverage, yet they can still offer substantial coverage for a wide range of services. On a month-to-month basis your premium will be less for a high deductible plan, but note that it will cost you more in the form of your deductible if you need to use your benefits for medical services. Lower deductible plans will most likely come with a higher monthly premium, but you will get to your cost shares (co-insurance) much quicker. Experience Momentum recommends looking at what services you used last year and whether you feel you'll need those services again in the coming year. You can easily determine whether paying a higher premium, but having more cost savings through co-insurance and a lower deductible will actually save you money or not. Questions? Email us at insurance@experiencemomentum.com. 

 

Is there a benefit to having a Health Savings Account (HSA)?

YES! Health savings accounts are usually offered when you are on a high deductible plan. A health savings account would be set up for you by your employee and a monthly or bi-weekly deduction would be taken from your pay check and put into this account. This money is PRE-TAXED! If you are offered an employer matched HSA, do it! Your HR department can help you understand what your HSA account may be used for, in order to help you determine if it is the right choice for you.

 

Who determines what my visit will cost?

When your healthcare provider, including those at Experience Momentum, agree to accept an Insurer's coverage (i.e. Regence, Premera), the provider signs a unilaterally binding contract that pre-determines what you provider will get paid. Each insurer pays differently regardless of what your provider actually bills. This is common practice across all healthcare institutions. 

 

What insurance companies does Experience Momentum recommend?

Experience Momentum does not have a preference on a specific health insurer, but we strongly recommend plans which have the following:

  • Physical Therapist coverage
  • Massage Therapist coverage
  • Registered Dietitian coverage
  • NO Prior Authorization
  • NO automatic medical reviews (i.e. every 12 weeks)
 

What's Experience Momentum's status on Medicare or Medicaid?

Experience Momentum will not be accepting Medicare, Medicaid or Apple Health in 2018 or 2019. We can still see you as a cash-pay client, or we can refer you to a clinic who does accept these payers. If you are seen as a cash pay client, you forfeit your ability to submit your care for reimbursement through Medicare or Medicaid. Experience Momentum will review its status on Medicare and Medicaid in 2020.

 

The plan I can afford does not provide the Physical Therapy, Massage or Nutrition coverage that I need. What can I do?

If there is not a plan that covers Experience Momentum's services, you can use our cash pay model to receive the treatment you need. Cash pay services allow you to be seen within a timeline that is best for your specific health goals and needs. Cash pay services also require less paperwork, allowing you to maximize the time with your provider, and eliminating the hassle of prior authorization. 

 

Still have questions? 

Email us at insurance@experiencemomentum.com