Understanding Your Insurance

Estimating the Cost of Treatment 

How much will treatment cost? We wish there was a simple answer to this perfectly reasonable question, but the only honest answer is: it depends on your insurance. And while our business office staff is dedicated to assisting you in navigating the complex (and often frustrating) world of health insurance, your treatment cost will depend almost entirely on your insurance network, your plan benefits, and the kind of treatment your child needs. 

The following information is for those with private or commercial insurance, usually through your employer. For information about Medicaid plans in Oregon or Washington, please skip down to the section below titled Oregon Health Plan & Washington Apple Health Managed Care (Medicaid).  

Your Insurance Provider Network

Private insurance companies contract with providers and facilities to offer “in-network” benefits to their members receiving specific services at specific locations. Seeing an “in network” provider almost always means a higher coverage level, and therefore lower cost to you. 

So the first step is always to determine whether Kartini Clinic is considered “in network” with your insurance plan. Every insurance plan insists on its own network; they decide which providers they agree to work with. The good news is Kartini Clinic – as one of the oldest and most respected pediatric eating disorder programs in the country – is considered “in network” with almost all major insurance carriers and many Medicaid plans in Oregon and Washington. You can have complete confidence that our intake coordinators and insurance specialists will determine network status before any treatment is rendered. 

Please note: if your insurance considers Kartini Clinic “out of network”, there often is no cap on out of pocket costs. Unfortunately insurance companies often do not make it clear to their members that if a benefit for out of network providers is, say, 80%, this will be 80% of the “usual and customary” rate (aka whatever price the insurance company has decided it is willing to pay), which might not be enough to cover the provider’s service charges or “billed rate”. If your insurance is out-of-network, the difference between the service charge or billed rate and “usual and customary” rate will be your financial responsibility. Please see the section below titled Our Treatment Services for more information about Kartini Clinic’s service charges and billed rates.

Obviously it is essential for our business office to be provided with complete and accurate insurance information prior to your initial appointment. If your insurance company does not include Kartini Clinic in its provider network, we will work diligently to obtain a “single case agreement”, a specialized agreement which provides benefits to you, very similar to “in network” levels. But please keep in mind, ultimately it is your insurance company that will decide what they will authorize and pay for.

Your Insurance Plan Benefits

Once you know your network status, the next step is understanding your specific benefits, especially mental health benefits, under your specific policy. Private insurance companies often sell many different plans; employers also frequently tweak benefits specifically for their employees. Again, our intake and insurance specialists will review your specific benefits – including specific exclusions – with you before any treatment starts.

Our Treatment Services

The price you pay is determined by the specific network contract your insurance company has approved as well as your benefits, such as deductible and co-insurance, at the time a service is rendered. 

Typically services are billed to insurance and you are financially responsible until you have satisfied your individual or family deductible. Once that happens, you will be paying your plan’s co-insurance until you reach your out-of-pocket maximum (OOP). When your out-of-pocket maximum has been met, all services that have been pre-authorized and performed by an in-network provider will be paid at 100%. 

Kartini Clinic collects charges you are responsible for on a week-to-week basis, based on your plan’s co-insurance amount. For example, if you have a high dollar deductible plan, you will not be responsible for the full deductible amount at the beginning of treatment. While in treatment you will be asked to pay co-insurance online or onsite on a weekly basis. We do also have payment plan options and potential financial resources available to you. If you have any questions please do not hesitate to contact your intake coordinator. 

Your Rights: No Surprise Billing Act notice

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for: Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:
∙ You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of network providers and facilities directly.
∙ Your health plan generally must:
− Cover emergency services without requiring you to get approval for services in advance (prior authorization).
− Cover emergency services by out-of-network providers.
− Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
− Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact U.S. Department of Health and Human Services beginning January 1, 2022 at 1-800-985-3059.

Visit No Surprises Act | CMS for more information about your rights under federal law.

Oregon Health Plan & Washington Apple Health Managed Care (Medicaid)

Kartini Clinic is contracted with multiple Medicaid plans in Oregon (aka CCOs) and Washington. We are also willing to work with all other Medicaid administrators to provide services through single case agreements. Please bear in mind that each Medicaid plan has its own policies and ultimately only they will determine if treatment at Kartini Clinic is authorized. And while we work hard to assist our families with Medicaid insurance, please know that the Medicaid authorization process for treatment can take some time.

Authorization for Treatment

The authorization process is one that plays a large part in treatment, whether you have private insurance or Medicaid. Unfortunately it is also one area of insurance usually not explained thoroughly enough to members. Kartini Clinic, as with similar high care treatment facilities, is required to have treatment dates approved in advance by your insurance. Securing an authorization and obtaining additional dates of treatment is something we are quite familiar with, which is why we like to be transparent about the potential risks of the authorization process. Insurance companies have the ability to discontinue the authorization for treatment at any point, leaving further treatment costs as out of pocket expenses to you. If we receive notice from an insurance company that treatment is no longer authorized, we immediately notify you and initiate the appeal process. We immediately schedule a meeting between our physicians and a physician at your insurance company to advocate on your child’s behalf for additional treatment days. But ultimately it is your insurance company’s decision whether to authorize treatment. Again Kartini Clinic will work with your insurance company to obtain any necessary treatment authorization(s), and notify you immediately of any denials. If you have more questions about the authorization process or how that applies to your insurance, please don’t hesitate to contact your intake coordinator or our business office.

Medical vs Behavioral Health Benefits

A quick word about another important aspect of health insurance that could affect you: the separation between “medical” and “behavioral health” benefits in certain private insurance plans (this distinction, thankfully, does not exist under Medicaid). In the same way that each private insurance plan has its own network, some private insurance plans use different companies to administer “physical” benefits versus the “mental health” benefits. In some cases, Kartini Clinic may be contracted or “in network” with one of these companies, but not the other (i.e. with your “mental health” plan but not your “physical health” plan). If your health insurance plan has separate physical and behavioral networks this means it will be vital that you understand your benefits and plan limitations.  For example, under some plans certain behavioral health benefits are limited or excluded entirely. Thankfully recent reforms, including federal and state “parity” laws and the Affordable Care Act (aka Obamacare), have done much to improve behavioral health benefits for everyone. However, exceptions do still exist, for example with employer self-funded plans and certain grandfathered individual plans (which some states have allowed to remain). Please reach out to your intake coordinator or our business office if you have any questions regarding medical vs behavioral benefits under your plan.

The Bottom Line

Understanding your insurance is crucial for eating disorder treatment, and we are here to help. We work closely with your family and insurance throughout treatment, but ultimately it is your insurance plan’s decision as to what they will authorize and pay for. But you can rest assured that our business office will always furnish you an estimated cost of treatment in writing, and review this information with you prior to the initial evaluation. If your insurance is out-of-network, an estimate of your out-of-pocket costs will also be given to you prior to your first appointment. We strongly recommend families verify coverage information with their plan by calling the number on the back of their insurance card.

If you have specific questions regarding insurance, please contact your intake coordinator at 971-319-6800. Be sure to also check out our Insurance FAQ page.