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Checking Your Insurance Benefits for the New Year

Happy holidays! It's that time of year when we get to slow down a bit, begin to plan for a new year, and....what's that...our insurance deductible resets? If you're like me you never learned about insurance as a consumer, you were just told you had to have it, here's your card, and what insurance doesn't owe the rest. Fun, right? Being on the other end of it I've learned that insurance is really tricky and at times really sneaky in hiding what benefits you actually have. Asking the perfect questions can change the game when it comes to insurance benefits. Below I've tried to give you a step my step process and script for calling insurance and getting information on your nutrition benefits.

  • Get your insurance card. It will look something like the one below. Below is a sample of what a card could look like. If you are not the subscriber you may need the subscriber's date of birth.

  • Call the number on the back of the card for "member services." You will most likely be directed to an automated menu. You are looking to speak to someone regarding benefits. The menu will tell you that you can check this online....ideally yes you can, but the online portal doesn't give you all the exceptions that may allow more nutrition counseling to be covered.

  • Once you are connected with a person you will need to provide your name, subscriber ID, and DOB (or this information for the subscriber of the account). After that you will get the chance to ask your questions. Here is a tentative script for you to follow, I've taken the liberty of filling out what I've heard on many insurance calls.

You: I'd like to check my benefits for nutrition coverage.

Them: What would that be called specifically?

You: Nutrition counseling benefits.

Them: Okay. Do you have codes for that?

You: 97802 for an initial assessment and 97803 for a follow up.

Them: Ah okay, it says here that you have no nutrition counseling coverage. Unless you have diabetes, then you'd have a 20% coinsurance.

You: No, I don't have diabetes. Does the coverage change dependent on diagnosis?

Them: What do you mean?

You: I have an eating disorder diagnosis and I know that the Affordable Care Act will sometimes change coverage with an eating disorder diagnosis or with medical necessity.

Them: Do you have a diagnosis code? (You can always give them z71.3, that is a general billing code for nutritional counseling. If they ask for a specific eating disorder code and you're a client of mine, then reach out to me!)

Them: Good question. I will have to check on that. Can I place you on a brief hold?

You: Sure.

Twenty-Five Minutes Later (Or longer)

Them: Thank you for holding. In checking with your policy it does look like you have 100% coverage under the Affordable Care Act with Medical Necessity.

You: Thank you. Does that apply for both in-person and virtual appointments?

Them: Yes, as of right now due to mandate we are covering both.

You: Are you planning on extending that into 2022? (I've gotten different answers about this dependent on the insurance company, some companies have this built in, some have voiced looking to discontinue this equivalent coverage.)

Them: Your plan covers telehealth services already.

You: Thank you. Can I have your name and the reference number for this call? (This is important if a claim is denied or you are later told you don't have telehealth can reference this call and they will go by what you were told.)

What if you don't have coverage under the Affordable Care Act for a diagnosis? Well, here are some additional questions to ask:

  • Coverage with medical necessity: The representative will not confirm your coverage under this. They will most likely refer you to the medical necessity policy and ask that the dietitian prove necessity as your clinician when they bill. If you have questions about it you can ask me (or your clinician if you're not my client), but most people have something under that policy.

  • What is my deductible?: Your deductible is the amount that you have agreed to pay out of pocket. A higher deductible plan means that you will pay less in premiums (the amount you pay each month) because you're agreeing to pay more out of pocket in the event that you need additional medical care. In most plans once you've "hit your deductible" your benefits change. For example, your deductible is $2500 and you were told you have no nutrition counseling benefits. It's important to ask Does my nutrition counseling benefit coverage change once I've hit my deductible? (Keep in mind that your deductible resets at the beginning of each calendar year!)

  • In some instances you may then only owe 20% coinsurance after reaching your deductible. What does that mean? Well, let's hypothetically say the cost of a session is $200. You would owe $40 per session and insurance would cover the rest.

  • Why does this matter? - Your deductible is ANYTHING you've paid out of pocket for sessions. So if you're going to the doctor, the eye-doctor, OBGYN, dermatologist, etc. and have paid any out of pocket costs, this gets applied to your deductible. Keeping track of your deductible will allow you to know when your benefits shift.

  • What if I'm paying out of pocket? - You can get what is called a Superbill which is a receipt for medical services. I provide these to clients on a regular basis. Then you need to submit this back to your insurance company for reimbursement. I recently learned about The Superbill, a company that will do this for you and finagle the insurance system to get you the most reimbursement possible. In return they charge 10% of what they collect from insurance. If you don't want to deal with insurance, it's a good way to see if you can get reimbursed. Anything that you're still responsible for out of pocket can be applied to your deductible.

This is just the tip of the iceberg when it comes to insurance and I hope it helps you feel a little more confident in reaching out to insurance and asking about your benefits!

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