Understanding Insurance Terms

Managed Care
A general term for how most healthcare in the U.S. is delivered. Insurance companies manage your access to both medical and mental healthcare through a network of providers (i.e. doctors, therapists, hospitals, clinics, etc) and the rules for how your healthcare referrals and coverage are determined.

HMO (Health Maintenance Organization)
This type of plan typically. requires a Primary Care Physician (PCP) to be the holder of your general care. Needs that extend beyond the scope of the PCP’s care require referrals. HMOs tend to have lower cost, but limited flexibility within their network

PPO (Preferred Provider Organization)
PPOs typically do not require a PCP to be holder of your care, which means you do not need a referral to see specialists. PPOs have a larger provider network, but these plans are often more expensive (including higher co-pays, premiums and deductibles (which are defined below).

EPO (Exclusive Provider Organization)
EPOs typically do not require a PCP to be the holder of your care, but they only cover care from providers within its network (except emergencies); they have no out-of-network coverage.

In-Network Provider is a provider, like Casa Pacifica, that has a contract with your insurance company. You’ll generally pay less when using in-network providers and some plans will only allow you to use In-Network Providers.

Out-of-Network Provider is a provider without a contract with your insurer. Typically, the care will cost more, unless the provider and insurer create a Single-Case Agreement (SCA). A SCA is when a provider, such as Casa Pacifica, creates a one-time contract which allows us to work with your insurance company, essentially providing in-network rates and care.

Annual Deductible
The amount you pay each year before insurance starts covering services. This rate is fully dependent on your insurance plan. For example, if your plan has a $400 deductible, you must pay $400 to your providers before your insurance plan covers the cost of services.  Your premiums, co-pays and prescription costs do not contribute to your deductible. You should be able to find your remaining deductible by calling your insurer or logging into their online portal, but we can also run these numbers for you.

Patient Responsibility
The cost you will pay for services. Co-Pay is a fixed rate that you pay to cover services, such as $50 per treatment admission. Co-Insurance is the percentage that you will be asked to pay towards the total cost of treatment. For example, if your insurance plan covers 80% of treatment, your responsibility will be 20%. Once we run your benefits, we will provide your specific Patient Responsibility. We can support your payment of these costs through payment plans or you can apply for CareCredit!  Co-Pays and Co-Insurances will have an Out of Pocket (OOP) Max, which is the maximum your plan allows you to pay annually. For example, you may have an OOP Max of $1000. After you cover that cost, your insurance will pay for the full cost of remaining services that year.

Authorization and Prior/Pre- Authorization are terms in which a provider seeks approval for services at or before the start of treatment. Some plans require provider to seek authorization before your teen can admit to treatment, while some allow us to complete the process after your teen arrives. Authorizations also happen on a regular basis (i.e. weekly) to gain additional treatment coverage for services such as Residential treatment. Requests for ongoing authorization occur through Utilization Reviews.

Utilization Review (URs) is the insurer’s assessment to ensure requested services are necessary and follow medical standards (also called Medical Necessity). Our clinicians and utilization review department stay in regular contact with your insurance company. This process can occur through a verbal report of progress, a written summary or by providing documentation from your teen’s medical chart; the format of URs is dependent on the insurance company’s case management team.

Denial
When your insurer believes the services are no longer required to follow medical standards.  Denials can happen at the start of treatment or anytime during treatment.

At Casa Pacifica, we will keep you updated if we believe authorization will be denied/coverage will be terminated. If coverage is denied, but our clinical team believes your teen requires more time in treatment, we can initiate a Peer Review (also called a Peer-to-Peer or P2P). In this process, our clinical team schedules a phone call with a physician or psychiatrist that works for your insurance company, where the providers discuss the treatment needs, symptoms and current safety of the teen. Most companies then allow for 48-72 hours for their physician to determine if additional coverage is provided.

If ongoing coverage is agreed upon, a new Authorization is provided. If additional coverage is not granted, a parent can choose to Appeal the decision. An Appeal is voluntary process a parent/guardian ask us to initiate, in which the insurer is asked to review (and hopefully reverse) a denial. You will be informed of all of these steps in greater detail if your child’s treatment coverage is at risk.

Mental Health Parity
The law requires insurance to cover mental health services on equal terms with physical health conditions, so if your plan covers unlimited visits for a physical condition, it must do the same for mental health.

Insurance shouldn’t be a barrier to care. At Camino a Casa, we’re here to support you through every step.  If you have questions about your insurance coverage, our admissions team is ready to help!

Contact us at admissions@casapacifica.org or at 805-366-4000.