Some insurance companies are now deciding not to cover telehealth sessions, because some of those flexibilities that were available during COVID are now stopping. The patient would need to ask insurance provider about telehealth coverage.

A deductible is the amount of money you must pay out of pocket before your insurance starts covering costs.

Example: 

If you have a deductible of $1,000, you must pay that amount for medical expenses before your insurance starts sharing the costs (except for services like preventive care, which may be covered before you reach your deductible).

Higher deductibles usually mean lower monthly premiums, but they also mean you’ll pay more upfront before insurance kicks in.

Co-insurance is the percentage of costs you share with your insurance company after you’ve met your deductible.

For example, if you have an 80/20 co-insurance plan, your insurance covers 80% of the costs, and you pay 20%.

Example:

You have a $1,000 deductible, which you have already paid. 

Your medical bill is $2,000. 

Your insurance covers 80% ($1,600), and you pay 20% ($400).

Co-insurance usually applies until you reach your out-of-pocket maximum, at which point your insurance covers 100% of covered costs.

A copay (or copayment) is a fixed amount you pay for certain medical services or prescriptions, typically at the time of the visit.

Example:

You visit a doctor, and your insurance plan has a $30 copay for office visits. You pay $30, and your insurance covers the rest of the bill.

You pick up a prescription, and your copay for that medication is $15. You pay $15, and your insurance covers the rest.

Copays are different from deductibles and co-insurance because they are fixed amounts rather than percentages or total costs you must reach first. Some services, like preventive care, might have no copay depending on your plan.

An out-of-pocket maximum (OOP max) is the most you will have to pay for covered medical expenses in a year. Once you reach this limit, your insurance covers 100% of additional covered costs for the rest of the year.

Example:

Your out-of-pocket max is $5,000.

You’ve already paid $1,000 in deductibles, $2,000 in co-insurance, and $2,000 in copays, totaling $5,000.

After reaching your out-of-pocket max, your insurance covers all further covered medical costs for the year.

What counts toward the out-of-pocket max?

✅ Deductibles

✅ Co-insurance

✅ Copays

What doesn’t count?

❌ Monthly premiums

❌ Out-of-network costs (depending on your plan)

❌ Non-covered services

This limit protects you from extremely high medical expenses by capping how much you have to spend in a given year.

It depends on your insurance company and your individual policy. 

1. Some insurance companies do not recognize developmental testing codes (96112, 96113)

2. Some do recognize developmental testing codes but have a limit on the units of code (96112, 96113). It's important to know these limits because if they are exceeded, the claim is denied and the patient becomes responsible for the full amount. 

For adults, it's typically two (2) units of 96113 and one (1) unit of 96112. For kids, it's typically eight (8) units of 96113 and one (1) unit of 96112. Kids are still developing so there is a lot more to rule out or consider.

Other options include:

Flex Spending Accounts (FSA)

Health Spending Account (HSA)

Not billing to insurance and negotiate a self-pay rate if needed (sliding fee scale)

If we are not in network with a patient's insurance provider, we have the option of providing patient with a Superbill that can be submitted to insurance provider for reimbursement. The patient would reach out to the insurance company and ask if their insurance policy would reimburse them for services associated with ADHD testing. Some insurance companies do not cover this, some do cover this entirely, and others may cover a limited amount. It just depends on the individual policy. Additionally, some insurance companies are now deciding not to cover telehealth sessions, because some of those flexibilities that were available during COVID are now stopping. The patient would need to ask about telehealth coverage.

If testing is covered and the patient does not have a deductible, then after the patient pays for services in their entirety, the clinician will provide the patient with a Superbill that they send to their insurance company. The insurance company will cut a check to the individual for reimbursement.

If the patient has a deductible, then the clinician will provide the patient with a Superbill after they pay for the services in their entirety. The patient will still submit the Superbill to the insurance company, and they will take that amount and subtract it from their total deductible due. 

Tina Schneider, Ph.D. accepts clients claiming on their OON benefits. 

Tina Schneider, Ph.D. is not in network with any Medicaid or Medicare plans.