COB stands for Coordination of Benefits. It refers to the process used by health insurance companies to determine the order in which they will pay benefits when a person is covered by multiple insurance policies.

Here's how it works:

When someone is covered by more than one health insurance plan (for example, they have coverage through both their employer and a spouse's employer), the insurance companies need to figure out which one pays first (the primary insurer) and which one pays second (the secondary insurer). The purpose of COB is to ensure that the total amount paid by all insurers doesn’t exceed the total amount of the medical bill, and that the insured person doesn’t receive more than 100% reimbursement.

Key Points of COB:

1. Primary vs. Secondary Insurance: The primary insurance pays first, up to its coverage limits. The secondary insurance can then cover some or all of the remaining costs, depending on its terms.
2. Order of Payment: There are rules to determine which insurance is primary and which is secondary. For example:
   • If you’re a child covered under both parents' plans, the birthday rule often applies: the plan of the parent whose birthday falls earlier in the calendar year is considered primary.
   • If you're covered under your own plan and your spouse's, your own plan is typically primary.
3. Not Duplicate Payments: COB ensures that the total amount paid by all plans does not exceed the total bill. For instance, if you have two plans that cover the same medical expenses, they’ll only reimburse you for the total amount of the expenses—not more than that.
4. Coordination Process: When a claim is submitted to both insurance companies, each company evaluates the claim based on its coverage rules and pays according to its terms. This helps avoid situations where the insured person might receive more than their medical costs.

Why is COB important?

• Preventing Overpayment: COB ensures that people aren’t reimbursed more than their healthcare costs.
• Maximizing Coverage: It allows people to make the most of having multiple insurance policies, potentially covering more of their medical expenses.

It can be a bit tricky when multiple plans are involved, but the system is designed to ensure that the process is fair and efficient.

A deductible in medical insurance is the amount of money you, as the policyholder, must pay out-of-pocket for healthcare services before your insurance coverage starts to pay. Essentially, it's the portion of your medical costs that you are responsible for each year, before your insurance company steps in and begins to share the costs.

Example: If you have a $1,000 deductible on your health insurance plan, you’ll need to pay the first $1,000 of your medical bills in a given policy year. Once you’ve met that amount, your insurance will begin to pay for covered services according to your plan's terms.

Key Points to Know About a Deductible:

1. Annual Reset: The deductible usually resets every year. For example, if your policy year starts on January 1st, your deductible would be the amount you need to pay before your insurance begins to pay for covered services for that year, and it would typically reset on January 1st of the next year.
2. Covered Services: The deductible typically applies to most medical expenses such as doctor's visits, hospital stays, surgeries, and lab work. However, preventive care (like annual checkups or vaccines) is often covered before the deductible is met, depending on the plan.
3. Shared Responsibility: Once you meet your deductible, your insurance will start covering a larger portion of your medical costs, but you might still be responsible for some costs, like copayments or coinsurance.
4. Coinsurance vs. Copayments: After meeting your deductible, you might still pay a percentage of the costs (coinsurance) or a flat fee (copay) for services.
5. Family vs. Individual Deductibles: If you have a family plan, there may be both an individual deductible (what each person must pay individually) and a family deductible (what the entire family must pay in total). Once the family deductible is met, the insurance may begin covering all family members, even if their individual deductibles haven’t been reached.

High Deductible Health Plans (HDHPs):

Some health plans are high-deductible plans, meaning the deductible is higher than average, but they often come with lower monthly premiums. These plans can be paired with a Health Savings Account (HSA), which lets you save money tax-free to cover medical costs.

Pros and Cons of Deductibles:

Pros:

• Lower premiums (you pay less monthly for insurance).
• Useful for people who don’t anticipate needing much medical care during the year.

Cons:

• High deductibles can make it harder to afford healthcare when you need it.
• You must pay out-of-pocket until the deductible is met, which can lead to financial strain in the case of an unexpected illness or accident.

In summary, a deductible is a way to share the cost of healthcare between you and your insurance company. The higher the deductible, the lower your monthly premiums usually are—but it also means you'll need to pay more out-of-pocket before your insurance starts covering a greater portion of your healthcare expenses.

A copay is a fixed amount that you pay for a specific medical service at the time you receive it, like a doctor's visit, prescription, or emergency room visit. The amount is pre-determined by your insurance plan. For example, you might pay a $20 copay for each doctor's visit, or a $10 copay for each prescription.

Example: If your plan requires a $30 copay for doctor visits, you’ll pay $30 when you see the doctor, no matter the total cost of the visit. Your insurance will cover the rest.

Key Points about Copays:

• Fixed amount (not a percentage).
• Paid upfront at the time of service.
• Common for doctor visits, prescriptions, and some other services.

Does not count toward your deductible (but it may count toward your out-of-pocket maximum, depending on your plan).

Coinsurance is the percentage of the total cost of a covered service that you are required to pay after you've met your deductible. For example, if your insurance covers 80% of a medical expense, you will pay the remaining 20%.

Coinsurance typically applies after you've paid your deductible, meaning you're responsible for a percentage of costs once the deductible has been met.

Example of Coinsurance:

• If you have a $500 medical bill and you've already met your deductible, your coinsurance is 20%.
• You would pay 20% of $500, which is $100.
• Your insurance would pay the remaining 80%, which is $400.

Key Points about Coinsurance:

• Percentage of the total cost (e.g., 20%, 30%, etc.).
• Applies after you've met your deductible.
• The amount you pay depends on the total cost of the service.
• Usually applies to larger, more significant medical expenses like hospital stays, surgeries, etc.
• Counts toward your deductible and out-of-pocket maximum.

To Sum It Up:

• Copay: You pay a set fee per service.
• Coinsurance: You pay a percentage of the cost of a service.

Key Differences:

• Aetna
• Ambetter
• BCBS
• Health Advantage
• BCBS Exchange
• Federal BCBS
• CIGNA (only accepted for psychological testing)
• Corporate Benefits
• Municipal
• Qualchoice
• Trustmark/Luminare
• UMR
• United Health Care
• WebTPA

The evaluation process consists of 3 separate appointments. The cost for each appointment is listed below:

Intake - $211.18
Evaluation - $1598.96
Results - $199.43

Intake - $175.98
Therapy - $166.19

Dyslexia and other learning disabilities are an exclusion with all insurance companies. This means insurance will not cover services for this and testing would be out of pocket.

The cost for each appointment would be as follows:

Intake - $280
Evaluation - $2000
Results - $250

We recognize that scheduling conflicts may occasionally occur. As a one-time courtesy, there is no charge for a missed initial appointment. However, any subsequent missed appointments without advance notice will incur a $50.00 fee.

• Cash
• Health Savings Accounts (HSA) / Flexible Spending Accounts (FSA
  • Please note that this does NOT include CareCredit
• Debit/Credit Cards
  • Visa
  • Mastercard
  • Discover

A patient estimate is an approximate calculation of the out-of-pocket cost a patient can expect to pay for a specific medical service or procedure. It's typically provided before the service is performed and is based on a combination of the provider’s charges, the patient's health insurance coverage, and any deductibles, copays, or coinsurance that may apply.

Key Components of a Patient Estimate:

1. Procedure or Service Cost
   The base cost charged by the healthcare provider or facility for the treatment, test, or procedure.
2. Insurance Information
   The estimate takes into account whether the provider is in-network or out-of-network, and what the patient’s insurance plan covers.
3. Deductibles, Copays, and Coinsurance
   Any portion the patient is responsible for paying based on their insurance plan’s cost-sharing rules.
4. Remaining Benefits
   The estimate may reflect how much of the patient’s deductible or out-of-pocket maximum has already been met for the year.
5. Non-Covered Services
   If any part of the procedure isn’t covered by insurance, the estimate may show that the patient is responsible for the full amount of those services.

Why Patient Estimates Matter:

• They help patients understand and plan for potential costs before receiving care.
• They promote transparency in healthcare pricing.
• They reduce the chance of surprise bills after treatment.

Important Notes:

• A patient estimate is not a bill; it’s a best guess based on current information and assumptions.
• Final charges may differ due to factors like changes in treatment, additional services, or updates from the insurance provider.

A patient statement is a document that provides specific details across one or more visits or procedures.

• It often includes:
  • Previous balances
  • New charges
  • Recent payments
  • Insurance payments and adjustments
  • Remaining balance
• Purpose: To keep the patient updated on the overall account balance

A patient invoice is a detailed bill for medical services rendered.

• It typically reflects charges for a specific visit or procedure, including:
  • Service dates
  • CPT Codes
  • Total cost
  • Insurance adjustments
  • Patient’s financial responsibility
• Purpose: To inform the patient of what is owed for a particular episode of care.