Understanding Your Insurance

Nice explanation about how insurance works!

There are many different insurance companies, large and small. Each company has its own rules, forms, pre-requisitions, fee schedule, reimbursement rates and many other unique things for us to do in order to be paid. There are variations even within each plan. Two people that work for the same company and insured by the same insurance carrier can have an insurance policy pay out differently for the same services.

Like you, we are contracted with the insurance companies and are required to charge you for all copay and patient responsibility charges.

Here are some important words that you may come across in your insurance policy:


The deductible refers to the amount of money that the insured would need to pay before any benefits from the health insurance policy can be used. This is usually a yearly amount so when the policy starts again, usually after a year, the deductible would be in effect again. Some services, like doctor visits, may be available without meeting the deductible first. Usually there are separate individual deductible amounts and total family deductible amounts.

If the deductible is $2,000, then you would pay cash for the first $2,000 in health care you receive each year, after which the insurance company would start paying its share. In every plan you can buy, preventive services will be covered in full even if you haven’t used up your deductible for the year. Some plans will also pay a portion of your costs for a few other services, usually doctor visits and prescription drugs, even before your deductible has been met. This is more common with Gold and Platinum plans but some Silver and Bronze plans also cover some services before the deductible has been met. The only way to figure out whether a plan covers some services “not subject to the deductible” is to study its provisions very carefully.


Co-insurance is usually a percentage amount that is the insured’s responsibility. A co-insurance of 80/20 means that the insurance company will pay 80% of the procedure and you are required to pay the other 20%.


The co-payment is a fixed amount that the insured is required to pay at the time of service. It is usually required for basic doctor visits and when purchasing prescription medications. This is a contractual agreement that you have with the insurance company. If you do not pay your copay, then the insurance will not pay for any services that would normally be covered during that particular visit.


This is the cost that you pay out of your own pocket. An out of pocket expense can refer to how much the co-payment, coinsurance, or deductible is. Also, when the term annual out-of-pocket maximum is used, that is referring to how much you would have to pay for the whole year out of your pocket, excluding premiums.

Lifetime Maximum

This is the most amount of money the health insurance policy will pay for the entire life. Pay attention to individual lifetime maximums and family lifetime maximums as they can be different.


The exclusions are the things that the insurance policy will not cover.

Pre-existing Conditions

This is something someone had before obtaining the insurance policy. Some health insurance plans will cover pre-existing conditions after a certain time period.

Waiting Period

This is the time one would have to wait until certain health insurance coverages are available.

Grace Period

This is the amount of time you have to pay your health insurance premium after the original due date and before insurance coverage would be canceled.
We practice medicine using evidence-based medicine and Bright Futures Guidelines set forth by the American Academy of Pediatrics. Insurance companies do not always agree, and therefore, do not always cover the typical costs associated with a visit. Depending on your contract, the insurance may simply not cover a procedure or add it to patient responsibility. Once added to patient responsibility, we cannot write-off a charge. Because of the differences amongst each plan, we cannot know what will and will not be covered.

The following are a list of commonly used CPT codes during well and sick visits. You can call your insurance company before your child’s visit to find out what is covered in your insurance contract.

  • Hearing: 92587 OR 92553
  • Hearing Instrument Screener: 92558
  • Vision: 99173 OR 92015
  • Vision Instrument Screener: 99174
  • Fingerstick blood sample: 36416
  • Hemoglobin: 85018
  • Lead: 83655
  • Lead Questionaire: 99420
  • Lipid panel: 80061
  • Urinalysis: 81002
  • Dental Varnish: 99188
  • Behavioral Assessment96127
  • Developmental Screening: 96110