Understanding Insurance Deductibles, Coinsurance, and Copays: A Guide for Eating Disorder Treatment
Navigating insurance coverage for eating disorder treatment can be overwhelming, especially when trying to understand terms like deductibles, coinsurance, and copays. These terms play a major role in what you’ll actually pay out-of-pocket for medical nutrition therapy (MNT) and psychotherapy.
In this post, we’ll break down each of these insurance concepts and explain how they typically apply when seeking treatment for an eating disorder. All numerical values in this post are for example only. Actual client responsibility is determined by our contracted rate with the insurance company.
The Intuitive Eating Center of Ohio is currently in-network with Aetna, Medical Mutual of Ohio, United Healthcare, Cigna and CareSource.
1. What is a Deductible?
Your deductible is the amount you pay out-of-pocket for covered healthcare services before your insurance starts to pay. Think of it as the threshold you must meet each year.
Example:
Let’s say your plan has a $1,500 deductible. That means:
- If you attend a $125 nutrition session, and you haven’t paid anything toward your deductible yet, you’ll likely pay the full $125.
- This continues until your total out-of-pocket costs for covered services reach $1,500.
- After you meet your deductible, your insurance begins sharing the cost of services—this is where coinsurance and copays come in.
2. What is Coinsurance?
Coinsurance is the percentage of costs you pay after meeting your deductible.
Example:
Let’s say your insurance offers 80/20 coinsurance after the deductible:
- You’ve met your $1,500 deductible.
- You go to a $150 therapy session.
- Insurance pays 80% ($120), and you pay 20% ($30).
Coinsurance amounts can vary between different types of care. Some plans may cover psychotherapy at a higher rate than nutrition services—or vice versa—so it’s important to check the details of your specific policy.
3. What is a Copay?
A copay is a fixed amount you pay for a covered service, usually at the time of the appointment. Unlike coinsurance, copays don’t depend on the total cost of the service.
Example:
- You have a $40 copay for psychotherapy and a $60 copay for nutrition visits.
- Whether the session costs $120 or $200, you still pay just the copay—assuming your deductible has been met or the service is not subject to the deductible.
Some plans require you to meet your deductible before copays kick in, while others allow copays from day one for specific services.
Applying This Treatment at The Intuitive Eating Center of Ohio
Eating Disorder Medical Nutrition Therapy (MNT)
- Generally subject to the full deductible or offered at a flat copay.
- Some plans limit the number of sessions per year unless deemed medically necessary.
Preventative Medical Nutrition Therapy (MNT)
- Covered benefit only for diagnosis for diabetes, hypertension, hyperlipidemia, or a family history of these conditions.
- Generally covered at 100% (does not apply to deductible, coinsurance, copay).
- Most plans limit the number of sessions per year.
- Requires physician referral for UHC and Aetna members.
Eating Disorder Psychotherapy
- Generally subject to the full deductible or offered at a flat copay.
- Normally unlimited sessions per year on most policies.
Tips for Navigating Your Benefits
We recommend all clients verify benefits and understand their individual policy. Clients are financially responsible for any denied claims.
- Call Your Insurance Company using the number on the back of your card.
- Confirm We Are In-Network Providers: Our Tax ID is 82-4920699 and NPI is 1013531953
- Ask about your benefits for psychotherapy and/or medical nutrition therapy using the codes below.
- Psychotherapy CPT codes: 90791 (initial assessment), 90837 (follow-up 60 minute session)
- Medical Nutrition Therapy CPT codes: 97802 (initial assessment), 97803 (follow-up session), 97804 (group education). If you have Cigna also ask about 99404 if you will have in-office sessions
- Specify eating disorder diagnosis versus preventative diagnosis (diabetes, hypertension, hyperlipidemia, or a family history of these conditions.)
- Ask About Deductibles and Out-of-Pocket Maximums: Know how much you’ll need to pay before insurance steps in and what the maximum limit is.
- Ask for a reference number for your call in the event a claim needs to be disputed.
- Obtain a Physician Referral: If you are an Aetna or UHC member seeking Medical Nutrition Therapy send this form to your Primary Care Physician
Download our Checking Benefits Guide for step-by-step directions when calling your insurance company.
