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Anxiety & Depression Help
Garden City Therapy LCSW
Navigating Insurance Deductibles, Copays and Coinsurances
Health insurance terms can be confusing and
overwhelming for clients and providers alike.
Here we try our best to explain some basics.
What is a deductible?
For mental health coverage, a deductible (if it applies) is the amount you pay out-of-pocket for covered services before your insurance company starts to share the cost. Once you meet your deductible for the plan year, you will likely only owe a copayment, coinsurance, or percentage for future sessions.
Mental health deductible:
The annual cost you pay first: The deductible is a set dollar amount that you are responsible for paying each year before your insurance starts to assist. For example, if your plan has a $1,200 deductible and a $30 copay, you will pay 100% of your mental health care costs until you've paid $1200 for the year and before your insurance covers part of the cost.
This does NOT mean that for a session/one service you pay $1200. It means that you pay the full contracted amount for the service each session ($80 for example) until you have met the deductible for the plan year. Additionally if you attend 4 sessions and pay $320 towards them and then stop therapy, you would NOT need to pay further towards the deductible as it applies to USE of services.
Example:
In-network therapist's contracted fee: $80 per session
Deductible: $1200
Copay: $30
You would pay $80 per session for 15 sessions ($1200) and then the cost would be reduced to $30 per session for the remainder of the year.
Deductibles reset annually: Your deductible resets at the start of each plan year. This means you will need to meet it again when the plan year renews before your insurance begins to cover costs again.
After meeting your deductible: Once you've paid the full deductible amount, your insurance will begin to cover a portion of your therapy costs. At this point, you will likely transition to paying only a copayment or coinsurance (the example of $30).
*Does not include premiums: The deductible is different from your monthly insurance premium. Your premium is the fixed amount you pay to your insurance plan, regardless of whether you use any services.
What are copays and coinsurances?
This pertains to the amount you pay aside from any deductible that may or may not apply.
Copayment: A fixed dollar amount you pay for each session ($30)
Coinsurance: A percentage of the cost you pay for each session (10% so for example 10 percent of $80 would be $8.00).
While most insurance plans have EITHER a copay OR a coinsurance it is possible for them to apply both and depends on your plan.
Another example:
In-network therapist's contracted fee: $80 per session
Annual deductible: $1200
Coinsurance: 20% ($16)
Here’s how your costs would be calculated:
First 15 sessions ($80 x 15 = $1200): You would pay the full $80 for each session. By the 16th session and for the rest of the plan year your 20% coinsurance kicks in. So, for the remainder of the year you pay $16.
Some plans either do not have deductible at all or the deductible does not apply to mental health services. When you start therapy here we get a quote from your insurance regarding deductible and copay/coinsurance and if your deductible applies.
Thank you and we hope this is of help.
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Garden City Therapy PLLC is committed to your privacy. Your information is confidential or private information regarding your health condition when completing any form and submitting to Garden City Therapy.
We are affiliated with and support the following professional organizations: Anxiety Disorders Association of America, NYS Social Work Office of the Professions, Mental Health Association of Nassau County as well as the American Psychological Association. Please visit other links to community and national mental health resources here.
Psychotherapy and Mental Health Counseling for adults. We are committed to providing affordable, quality, mental health care by the best therapists in Long Island. We have extensive prior experience working at numerous mental health clinics in Long Island and Queens, we have provided counseling and psychotherapy to individuals with anxiety, depression, trauma, PTSD, difficulty adjusting to life changes, abandonment and trust issues, as well as other areas of exploration. We have Masters Degrees in Social Work and/ or Mental Health Counseling. Executive Director, Michelle Ambalu, LCSW has supervised social work students learning to practice psychotherapy and all of out clinical staff meet weekly to engage in advanced supervision towards advanced clinical credentialing and for the purpose or best treatment practices as seen fit by the state of New York. Services are $80 per session out of pocket. We also accept most Cigna, Empire BCBS, Fidelis (and Medicaid), Optum UnitedHealthcare (and Medicaid) Oxford, Community Plan Medicaid, Healthfirst (and Medicaid), Magnacare and UMR insurance plans. We also submit claims for NYSHIP for out of network reimbursement and by doing are able to match your in-network copay. Fully HIPAA compliant telehealth counseling services.
