Understanding Your Insurance Coverage

 

So how much is this going to cost me?

We wish there was a simpler answer to this perfectly reasonable question. But the only honest answer is: it depends. Our business office staff is dedicated to assisting you in navigating this complex (and often frustrating) world of health insurance. Kartini Clinic is also committed to complete transparency about our charges; we make them publicly available for anyone to see. But prices are far from the whole story. When determining how much treatment will likely cost you, the first important question is whether your insurance company includes Kartini Clinic in its provider network.

Provider Networks

Seeing an “in network” provider almost always means a lower direct cost to you (i.e. your “co-insurance”, the amount you pay until you reach your annual “out-of-pocket maximum”).

Fortunately Kartini Clinic is contracted with most large health plans, both regionally and nationally, and our Business Office spends a great deal of time working with you and your insurance company to determine your benefits (including limitations), and likely out-of-pocket expenses. However, if you are out of network, there often is no cap on OOP costs; insurance companies often don’t bother to explain that when they state they will pay “100%” that means 100% of “usual and customary” (insurance speak for the price insurance companies are willing to pay) which might not be enough to cover what a provider charges for their services. When you are out-of-network, the difference between a provider’s charges and “usual and customary” payment is the patient’s financial responsibility.

So it is essential that you provide our business office with timely (i.e. before an appointment takes place!), accurate and complete insurance information. But even if your insurance does not have Kartini Clinic in its network, we do our best to work with your insurance on a single case basis (these types of agreements includes an agreed rate for services, so plan members don’t pay more out of pocket than they would going to an in-net provider). Bear in mind, ultimately it is your insurance company that will decide what they will authorize and pay for.

Oregon Health Plan (Medicaid)

Kartini Clinic is contracted with Family Care to provide services to it’s members on the Oregon Health Plan. And we are dedicated to working with any and all Oregon Medicaid administrators who are willing to authorize treatment at Kartini Clinic, but please be advised that OHP plans vary greatly by county, with each having their own requirements, policies, and procedures. Ultimately, it is up to them, not Kartini Clinic whether they will authorize treatment. In our experience it is essential for you to locate a case manager with your Plan who can advocate on your behalf.

Authorization for Treatment

Parents are often told by their insurance company that “everything will be covered”. Not surprisingly it’s often a little more complicated than that. What insurance companies probably mean to say is “it could be covered” (because it’s not specifically excluded) as long as they agree that a service is “medically necessary.” And who get’s to decide what is medically necessary? Parents? Doctors? Sadly, no. It’s the insurance company who gets to decide. Parents often seem reluctant to believe this. We are routinely asked “what we said” (or didn’t say) to cause an insurance company doctor to deny further treatment. Unfortunately, it’s the insurance company’s money (or your employer’s, who hired the insurance company) and they decide what they will pay for. Kartini Clinic will work tirelessly with your insurance company to obtain any necessary treatment authorization(s), and notify you immediately of any denials. Of course there are appeals processes for a denial of medical necessity, but these often take weeks to complete; in the meantime families have to make tough decisions about continuing treatment that could result in substantial financial burdens to them if an appeal is not successful. In other words, knowing your benefits in advance and going to an in-network provider is only part of insurance challenge facing parents. 

Medical vs. Behavioral Health Benefits

As if all of this were not enough, parents of a child with an eating disorder often have to deal with an entirely arbitrary distinction created by insurance companies between so-called physical health (i.e. “real” medicine) and behavioral health, which is often code for illnesses blamed on the patient and/or parents. Under some Plans certain behavioral health benefits are limited or excluded entirely. Thankfully recent reforms, including federal and state “parity” laws and the Affordable Care Act (aka Obamacare), have done much to improve behavioral health benefits. However, exceptions do still exist, for example in employer self-funded plans and certain grandfathered individual plans (which some states have allowed to remain).

The Bottom Line

The reality of healthcare in this country is that parents must understand their own insurance. You will ultimately be financially responsible for the cost of any treatment your insurance company refuses to pay for. That’s why our business office always furnishes a written estimate of treatment costs to you, including a paper copy of your benefit information provided to you at your first appointment. If you have out-of-network insurance an estimate of your out-of-pocket costs will also be given to you prior to your first appointment. We recommend patients always verify any information directly with their insurer.

If you have specific questions regarding insurance, please contact our intake coordinator at 971-319-6800. Be sure to also check out our Insurance FAQ page.

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