Insurance Holder Information Detailed below are important terms related to insurance recipients to help clarify the financial responsibilities for healthcare services. Please note that copays and costs for services are due at the time of service. We would also like to inform you that certain services, such as court-ordered services and couple/marital counseling, are not covered by insurance. It's important to understand that until your annual deductible and out-of-pocket maximum are met, you will be responsible for covering the full cost of your services. Once these thresholds are reached, your insurance plan will begin to cover eligible expenses. Please also be aware that insurance companies often have specific requirements for prior authorization and may place limits on the types or amounts of services they will cover such as limits to 6 sessions. These requirements and limitations can vary significantly between insurance providers. Therefore, you may receive a bill for any remaining balance that your insurance plan does not cover. We strongly encourage you to contact your insurance provider directly if you have any questions regarding the specifics of your plan and limits. They will be the best resource for detailed information about your coverage. _____________________________________________________________ What is Prior Authorization? Prior authorization (PA) is a utilization management (UM) process used by insurers (both commercial and Medicaid) to determine if a prescribed product or service will be covered. Insurance companies require prior authorization for behavioral health services in Kentucky (including peer support, community support, IOP/OP, and Targeted Case Management), to ensure reimbursement and avoid financial penalties for the practice. Providers must obtain authorization before initiating or continuing services, and enrollees may experience reduced benefits if authorization is not obtained. What is a Deductible? A deductible is the amount you pay for healthcare services before your health insurance begins to pay or cover services. For example, if your plan has a deductible of $1,000, you must pay the first $1,000 of your medical bills before your insurance covers any costs. There are different types of deductibles, including individual and family deductibles, which can vary based on the insurance plan. High-deductible plans typically have lower monthly premiums but require you to pay more out-of-pocket before coverage kicks in, while low-deductible plans have higher premiums but lower out-of-pocket costs. What are Out-of-pocket costs? Maximum out-of-pocket limits: The most you will pay out-of-pocket annually for coverage. If you meet that limit, your insurer will pay 100% of all covered healthcare costs for the rest of the plan year. What is a Copay? A copay, or copayment, is a fixed amount you pay out-of-pocket for specific healthcare services at the time you receive them, such as doctor visits, specialists, or prescription medications under a health insurance plan. When you visit a healthcare provider, you may be required to pay this amount regardless of the total cost of the service. Copayments generally don’t contribute to a deductible. However, some insurance plans won’t charge a copay until after your deductible is met. It is one way that health insurers share costs with patients while encouraging them to seek necessary healthcare without deterrent. For instance, you might pay a $25 copay for a standard doctor's visit and a $50 copay for a specialist visit. Amounts vary based on plan. What is Coinsurance? Coinsurance is the percentage of costs that an insured person pays for covered medical expenses after meeting their deductible. For example, if your health insurance plan has a coinsurance rate of 20%, you will pay 20% of the costs for services after your deductible is satisfied, while your insurer pays the remaining 80%. Coinsurance typically applies to various medical services, including hospital stays and office visits. **Anthem commercial insurance information on deductible, copay, and coinsurance: Understanding Deductibles When Choosing Your Health Plan | Anthem https://www.anthem.com/blog/understanding-health-insurance-deductibles Aetna Medicaid- Effective June 25, 2025, prior authorization (PA) will be required for behavioral health services, including Substance Abuse Disorder (SUD) services, for all members. Additionally, effective July 1, 2025, prior authorization will be required for all individuals receiving TCM services. Passport Medicaid- Prior authorization will be required for behavioral health services, including Substance Abuse Disorder (SUD) services, for all members in Kentucky, effective from July 1, 2025. WellCare of Kentucky Medicaid- WellCare of Kentucky requires prior authorization for behavioral health services and procedures, effective July 1, 2025. Humana Medicaid- Humana Healthy Horizons requires prior authorization for Effective July 1, 2025, per the Kentucky Department for Medicaid Services prior authorization (PA) guidance issued to providers on April 8, 2025, Humana Healthy Horizons in Kentucky will reinstate all PA requirements for behavioral health services in the Medicaid program. UnitedHealthcare Medicaid- Beginning June 25, 2025, UnitedHealthcare Community Plan of Kentucky will require prior authorization for some behavioral services. Health care professionals providing inpatient and outpatient services to UnitedHealthcare Community Plan of Kentucky members must follow the prior authorization