Insurance is a headache. Let’s navigate it together.

We understand these terms are confusing, and not everyone gets the opportunity to learn what it all means.

Every plan is unique and often changes over time. If you have commercial health insurance through your employer, your parents’ employer, or if you purchased a plan through the Healthcare Marketplace, the following descriptions give a general understanding of what these terms mean, and how they apply to your care:

1. An insurance premium is the amount you pay monthly to have health insurance. This is similar to a monthly gym membership - you pay it each month, and you’re allowed to use their services.

2. Some insurance plans have a deductible, which is the amount of money out of pocket that you are responsible for paying before your insurance starts to pay for medical services. This amount is separate from your insurance premium and can vary significantly from plan to plan. A service may be covered under your plan, but if you have a deductible, you’ll still be responsible for paying for the cost of that service in full until the deductible is met. Your premium payments do not count toward your deductible.

   Sticking with the gym membership example: Imagine if you had a gym membership that allowed you to enter the building after you pay your monthly membership fee (the premium), but in order to use any gym equipment you needed to pay a price out of pocket for each machine before being able to use them whenever you want. The deductible is the fee for using the machine.

3. An insurance copay is a fixed, pre-determined portion of the cost that you pay when you use your health insurance for healthcare services. Sometimes an insurance plan only has a copay for services and no deductible; some plans have a copay that applies after the deductible is met. Generally this means that you pay a small fee - often anywhere from $5-$50 - and your insurance covers the remaining cost of the service. Many times, services like primary care visits or routine mental health sessions will only have a copay applied, and the deductible may only apply for specialist services.

   In our example gym, this would be similar to paying a fixed, smaller portion of the “machine fee” each time you use it (either after or instead of meeting your membership’s deductible), and the gym covers the remaining amount.

4. Some health insurance plans have a coinsurance instead of a copay. This is common when using out-of-network benefits. Instead of a fixed, pre-determined portion to pay for services, a coinsurance is a pre-determined percentage split that you and your insurance will follow for a given service. Since each service likely costs a different amount from the next, the percentage split may change between providers or services.

   In our example gym, this would be similar to a policy that says you will pay 30% of the fee to use a given machine, and the gym will cover the other 70% of the fee.

5. A final common insurance term is an out-of-pocket maximum. This includes any payments you make toward your deductible as well as any copay or coinsurance payments for services, but does NOT include your premium payments. Once you pay this amount out-of-pocket in a 12-month period, your insurance will pay for covered medical expenses in full.

   This number is often quite large, and an individual or family plan may not reach this amount in a given year, unless you use your insurance for routine and/ or high-cost services.

6. Lastly: Insurance plans are typically active for a 12-month period, after which they will renew / reset. Oftentimes, insurance plans will be active January 1 - December 31, or a full calendar year. However, if you started a plan in the middle of a calendar year - either your job changed plans, or you had a change in employers, or you applied for Medicaid, etc. - your plan will reset in the month it originally became active and will cover the following 12 months.

   When your insurance plan renews every year, the amounts you pay for your premiums, deductibles, copays, coinsurances, and/or out-of-pocket maximums will reset. This means that you will start over - your deductible and your out-of-pocket maximum reset, and you will need to start paying toward them until your copays or coinsurances begin again.

   Additionally, when your plan resets at the end of the 12-month period, the amounts you pay for any of these may change. Sometimes this is because your plan changed slightly (or significantly), and sometimes the insurance provider simply increases their premiums (or government subsidies impact how affordable plans are, etc.). When you renew your health insurance, we recommend being as diligent as possible to be aware of & prepare for these changes, as well as contacting your insurance provider if changes happen and you aren’t notified of them, or if you notice a change and don’t understand why they’re happening.

When a person is approved for a Medicaid plan, they’ll receive a mailing with their member ID (similar to a Subscriber ID) and eventually receive an insurance card - typically, a green card with a blue stripe at the top, and a dotted picture of the state of Michigan. This card verifies that the person has a Healthy Michigan Medicaid plan - also known as “Straight” or “Traditional” Medicaid. Healthy Michigan Medicaid is provided and managed directly through the State of Michigan. All plans begin as a Healthy Michigan plan.

The alternatives to “Straight Medicaid” are known as Medicaid HMOs (also known as a Health Maintenance Organization, or a Managed Care Organization). Michigan contracts private health insurance companies to manage Medicaid recipients’ plans instead of the State managing them. This is how a person could have a Medicaid plan that’s part of Priority Health, for example: the plan is a Medicaid plan, managed through Priority Health. After the first month or so of having a Healthy Michigan Medicaid plan, your plan may switch to being managed by an HMO. You may also have the same HMO for months or years in a row, and unexpectedly be switched to a different HMO - and Medicaid may not give you advanced notice of these changes. This can result in your care with us or other providers being disrupted if they don’t accept your new HMO, and may result in claims being delayed or denied if the claims are sent to the wrong HMO on accident.

If your Medicaid plan ever changes unexpectedly, we encourage you to take the following steps:

• Reach out to your Medicaid case worker directly. They should be able to tell you the timeline for when your plan was changed, and who it was changed from / to.

• Reach out to us and any other providers you’re receiving services from once you realize your plan has changed or is going to change. That will give us some time to prepare for it, which will help ensure claims are submitted smoothly.

• If your Medicaid HMO is changed to a company we are not in-network with (at the moment, this includes HAP, Aetna, Molina, or McLaren Medicaid options), we can explore the possibility of requesting out-of-network coverage.

• If we cannot secure out-of-network coverage, you also have the right to contact Medicaid and request they reassign your plan to an HMO we are in network with. We cannot tell you which HMO to select, but we do encourage you to select an HMO that is accepted by as many of your healthcare providers as possible.

If you have a Medicaid plan, you either may not have any premiums, nor a deductible, copays, or coinsurances, or you will be responsible for a very small amount of a covered service.

If you are part of what is called a “209(b)” or a “medically needy” program, you may have what is called a “spend down amount”, which is equivalent to an insurance deductible. After you meet this deductible, your Medicaid coverage should apply and begin covering your medical services.

If you have a Medicaid plan and you notice you have an unusual outstanding balance, it’s possible that your coverage was terminated and you either were not notified, or you missed the notification. It’s also possible that there was a billing error and the insurance company rejected it, applying the balance to you. If you notice this happen, please reach out to your therapist and bring it to their attention so you can identify and resolve the problem together.

If you have an active Medicaid plan that is not a spend-down plan, it is not legal for us to charge you any amount for our sessions, and we also cannot apply late cancellation or no call - no show fees to your account.

In this situation, the Commercial plan (whether you purchased it through the Healthcare Marketplace or if it is provided through your employer or a parent’s employer) is referred to as the “primary insurance” plan, meaning it’s the first company to receive claims from providers. Once the claim is received and processed, the primary insurance will reimburse their contracted rate, leaving you with either the deductible, copay, or coinsurance amount you’re responsible to pay. This greatly depends on what your plan entails - please refer to the first FAQ at the top of this section for more information on what this means generally. Please also contact your insurance company for more information about what this would mean for you.

After your primary insurance pays their portion, a separate claim will be sent to your Medicaid plan - referred to as the “secondary insurance” plan - requesting reimbursement for whatever the primary insurance didn’t pay for. This process applies no matter if you have a Healthy Michigan Medicaid plan or a Medicaid HMO.

Example: Jane has a Blue Cross Blue Shield (BCBS) primary insurance and a Medicaid secondary insurance. We send a claim to BCBS requesting reimbursement for $200 55-minute therapy session. Jane’s plan has a $1000 deductible, which she hasn’t met yet. BCBS will process the claim, noting that she hasn’t met her deductible yet. They’ll let us know that Jane owes $160 for the session - the amount that BCBS has contracted to pay for our $200 session, but is currently (from BCBS’s perspective) Jane’s responsibility. Then, we send a second claim to Medicaid for the same session, requesting they cover the $160 deductible payment for Jane. Medicaid will process the claim, then pay the amount they’ve contracted to pay for a session, which is $101. The remaining balance between the BCBS and Medicaid contracted rates ($160- $101 = $59) gets written off by Jane’s provider as “uncollectible” - meaning neither of her insurance plans will pay it, and it cannot be billed to Jane as a Medicaid recipient.

We will always work with you to submit claims to your primary insurance and secondary insurance plans. If there are any changes in your insurance coverage, or you add a secondary Medicaid coverage, please let your therapist know as soon as possible so we can be sure to submit claims accurately and minimize confusion for us and for you!

If you lose your health insurance (or unexpectedly change insurances to a plan we cannot accept) while you’re a client at Queering The Pathways, we’ll work together to find the best option moving forward. Our goal is to maintain your connection to quality care, no leave you hanging when circumstances change. This could include, but is not limited to:

• Supporting your application for Medicaid or a Healthcare Marketplace insurance plan

• Switching to a private pay agreement that reflects your financial situation - either temporarily or permanently

• Finding a different provider who can accept your new insurance or provide services at low/no cost to you (if this is the best option at the time)

In the event this happens to you, please tell your therapist as soon as possible so you can find a solution quickly and smoothly.

We at Queering the Pathways understand that financial circumstances change all the time! If you’re having a difficult time making full session payments, we’re happy to work with you to establish an affordable payment plan schedule or, if necessary, to revise your private pay agreement to a more affordable session price.

With established private pay agreements, we do recommend establishing a routine amount you can pay toward your balance. This is intended to avoid a common occurrence: the balance grows with each session you attend, and suddenly the balance is much larger than you expected. Making regular payments - even if it is $5 or $10 per week - can make a big difference at slowing the balance from growing out of hand.

We want to respect your concerns about privacy and security. Simple Practice is a HIPAA-compliant system that has received HITRUST certification, which is considered the gold standard in healthcare security. In the unlikely event of a security or data breach, the moment we find out about it, we will contact you directly to alert you to the breach as well as the steps we’re taking to resolve it.

If you choose to store your credit card information in Simple Practice, we will only charge your card with your permission and consent. It is required to have a card on file if you sign up for AutoPay, which will charge your card automatically the night that any balance is applied to your account.

If you are worried about having your card information stored in Simple Practice, you’re welcome to talk with your therapist about alternative methods of payment.

Client balances can grow quickly for a variety of reasons. Some of these reasons include but are not limited to:

• Multiple session claims being processed at once, meaning multiple sessions worth of copays, coinsurances, or deductible responsibilities can show up suddenly

• Multiple weeks have passed since you reviewed your invoices, allowing more time for accruing a balance

• Insurance companies denying or rejecting claims, leading to our billing system to apply the billed amount to you, rather than the insurance company.

In the event your balance is larger than you expected, or if you see something on an invoice you don’t understand, please reach out to your therapist immediately so we can understand what’s happening and make a plan to address it together.