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When you first enter your insurance information on Thrizer, you will get an immediate breakdown of your out-of-network coverage for therapy.
The breakdown of your insurance benefits will include several different terms that are important to know for you to truly understand your net cost for therapy.
Allowed amount: The allowed rate is the maximum amount that the your insurance will accept and reimburse for therapy. It is not necessarily the same as the amount that your clinician charges you.
Deductible: The amount you must pay out-of-pocket before your out-of-network insurance coverage begins.
Co-insurance: The percentage of allowed amount you are responsible for after you've met your deductible.
Estimated Reimbursement: The estimated payment you will receive from your insurance for a therapy appointment.
Your out of pocket cost for therapy sessions is determined by the deductible, allowed amount, and co-insurance.
Deductible: You often have to meet a deductible before starting to receive reimbursements for sessions. That means that you will pay your provider's full fee for all sessions until you meet your deductible. For example, if your deductible is $1000 and your provider's session fee is $200/session, you would pay the full $200 fee for the first 5 sessions before receiving reimbursements for each session.
Once the deductible is met: Your out-of-pocket cost is the difference between the provider's fee and the reimbursement amount from your insurance. So, if the provider's fee is $200 and insurance reimbursement is $150, you would owe the $50 difference. This would be your net out-of-pocket cost.
Reimbursement rates vary based on individual insurance plans. The reimbursement rate provided in the benefit check is just an estimate, and is calculated from the your co-insurance and allowed rate for out-of-network mental health services.
Allowed amount: Remember, the allowed amount is the maximum amount the insurance plan is willing to reimburse for therapy sessions, e.g. $120 or $150. This is not necessarily the same as the amount you are charged.
Allowed amounts are generally decided at the time of the first claim submission, but we provide an estimate of your plan's allowed amount when you first link your plan. Once you submit the first claim, your allowed amount for your plan will update in your profile automatically.
Co-insurance percentage: Sometimes, you will owe a portion of the allowed amount determined by your co-insurance percentage in your health plan, e.g. 20% or 40%.
Let's run through an example: If your plan has an allowed amount of $150 with a co-insurance of 30%, insurance will reimburse the remaining 70% of the $150 allowed amount, which is $105 reimbursement per session. Therefore, if the provider's fee is $150/session, your out-of-pocket cost or co-insurance is $150 - $105 = $45/session.
In other words, your out-of-network benefits dropped your session fee from $150 to $45 a session!
Use the co-insurance calculator below to plug in your provider's fee, amount remaining on deductible, allowed amount, and co-insurance percentage to get your out-of-pocket costs!
