Tag: out of pocket

Woman trying to understand EOB

The Difference Between Co-pay, Co-insurance, Deductible and Out-of-Pocket

Understanding the difference between co-pay, co-insurance, deductible and out-of-pocket costs on an Explanation of Benefits (EOB) for Pediatric Therapy can be confusing. Your insurance should provide guidance, but this may help you sort it out.

It’s likely that you have questions such as:

  1. What is a co-pay?
  2. What is the difference in co-pay and co-insurance?
  3. Who do I have to pay for my deductible?
  4. Will, I ever not have to pay co-insurance?
  5. What is the difference between in and out of the network?

A Co-payment (co-pay)

Co-payment is a fixed amount your insurance determines to be your portion to pay per visit. This payment can also be different based on what type of visit you are having. Such as office visits, specialist visits, ER visits, etc.  Pediatric Therapy is considered a specialist visit. Co-pay usually does not apply to a deductible. 


Co-insurance is the percentage your insurance has agreed is your financial obligation to pay. Your insurance plan will pay a percentage of covered expenses, and you would pay the remaining percentage. This amount can vary depending on whether or not your provider is in or out of network with your plan. Your insurance company will start applying charges to your co-insurance once your deductible is met.

Your Deductible

Your deductible is the portion of your medical expense that you would be financially responsible to pay PRIOR to your insurance paying their portion of your co-insurance. Deductibles typically start over at the beginning of the year, but that can vary from plan to plan. Pediatric Therapy claims applied to your deductible are your full responsibility. Your deductible amount may be different based on whether your provider is in-network or out of network with your plan. If a covered claim is applied to your deductible, you would pay the provider for the amount your insurance deems is your responsibility.

An Out-of-Pocket maximum

Out-of-pocket maximum is a pre-determined amount your insurance company deems to be the most you have to pay per year for medical expenses. When you reach this amount, your insurance will begin to start paying your allowed medical expenses at 100% for the remaining portion of the benefit year. 

In and out of Network:

Your insurance may provide a smaller deductible and smaller co-insurance portion if you choose to see a provider the insurance company has a contract with. This can be large cost savings for you. For example, if you were to have Pediatric Therapy with an in-network clinic, you may have a $500 deductible, with 90% co-insurance (you owe 10%) and a $2500 out-of-pocket max.  If that treatment is provided at a clinic that is NOT contracted with your insurance, you may see that your deductible is now $1500, and your co-insurance is now 70% (you are responsible for 30%) with a $5000 out-of-pocket max. 

Understanding your insurance benefits can be an overwhelming task. Above all, one of the most important things to know when you make appointments for services, such as Pediatric Therapy, is to ask your insurance company if the clinic is in or out of network with your plan, as you may have a much larger portion that is your responsibility to pay if they are out of network than you had thought. 

BDI Playhouse offers support with understanding your pediatric therapy benefits. Our knowledgeable office team provides information and guidance to streamline and support processes to save your precious family time.

Written by:

Ann Marie Johnson

BDI Playhouse Insurance Billing Specialist and Assistant Office Manager

Insurance & Billing For Current Clients

Insurance and Billing Information

Providing the best services for your child requires a HIGHLY TRAINED TEAM of therapists AND office professionals.

Our knowledgeable office team provides information and guidance to streamline and support processes that save your precious family-time. Securing coverage or providing a plan that allows your child to receive uninterrupted QUALITY services is our goal.

If you have questions, we have answers. Call us any time or schedule a call with our office at a time that is convenient for you HERE.

100+ years of combined office and billing experience

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Insurance & Billing For New Clients

Insurance & Billing For New Clients

For general information related to coverage guidelines that commonly apply, please select your insurance below:

  • Blue Cross Blue Shield

    • BDI Playhouse is in-network with BCBS PPO plans. 
    • BDI is not in-network with BCBS HMO plans.
    • Most plans have generous Pediatric Therapy benefits.
    • Some plans limit coverage so please check with your carrier for any limitations on your policy.
  • Aetna

    • Most Aetna plans only cover speech therapy when it directly relates to a birth defect, brain injury, stroke, or head trauma.  Review Aetna’s policy regarding Speech-Therapy coverage for more information.
    • Aetna does not cover the cost of Aquatic therapy.  BDI offers a Private Pay rate if services are not covered. 
    • Aetna allows one appointment maximum per day.  
    • While your plan may have an annual visit allowance, that is not considered a guarantee of coverage. Coverage of services is always dependent on medical necessity, not the policy’s annual visit limit.



  • United Healthcare

    • BDI Playhouse is not in-network with United Health Care Plans. 
      • Therapy can be billed to UHC and will process to your Out of Network benefits
      • Specific billing codes can be provided to help you confirm coverage.
  • Private Pay Discount Details

    In the event that insurance funding is not available, or services are limited or not covered by the policy, our private pay discount rate offers parents another option. Details on the discount for our affordable private pay rate options can be found here.


  • Early Intervention Funding

    Early Intervention (EI) is a state-funded program offering services to children birth to age three with a qualifying level of delay or qualifying diagnosis. 

    • EI serves as a secondary insurance: Providers bill your insurance first and then Early Intervention for portions not covered by your plan.
    • A monthly family fee typically applies
    • Services are often required (by the program) to be provided in the family’s home and children with this funding source are rarely approved for services in-clinic at BDI. 

    Many families receive services BOTH through the Early Intervention AND separately through their insurance so that they may receive services in clinic, allowing the best of both worlds in their child’s intervention. 

    Waiting periods in Early Intervention are common. We recommend scheduling a free screening or consultation at BDI Playhouse prior to starting the Early Intervention evaluation process, as we can typically schedule within one week.  We can also offer services temporarily while you wait for Early Intervention to complete the initial evaluations, schedule a meeting to generate the service document called an IFSP, and assign treating therapists. 

    More detailed information regarding this program can be found here.

    Please review the Early Intervention website, but do not hesitate to ask us to walk you through how the Early Intervention Program works and how accessing this resource might benefit your family. 

  • Cigna

    Starting January 1, 2023, BDI Playhouse will not be in-network with Cigna PPO plans. 

    • Therapy can be billed to Cigna and will process to your Out of Network benefits
    • Specific billing codes can be provided to help you confirm coverage.
  • Other Insurance Plans

  • Multiplan Network participant: offers a 10% discount for Out of Network claims


Claims billed to any other insurance plan would process to your Out of Network benefits coverage.

  • HMO Plans

    • We are contracted BCBS Ingalls HMO. 
    • For other HMOs ask your child’s pediatrician to provide assistance in requesting a “single case agreement or waiver” to allow for coverage outside the network, at your in-network level of benefits. Click here for instructions to begin that process.  
    • If coverage cannot be secured, please consider our private pay discount rates. 
  • Medicaid and State Plans

    • BDI is not contracted with Government supported plans such as Medicaid or any State-funded plans (Illinois Medicaid, BCBS Community, Illinicare, Meridian, Health Alliance, Aetna Better Health, County Care, etc).
    •  We offer a significantly discounted private pay rate. Please see the attached link for more information.


  • DSCC

    • DSCC: is the Division of Specialized Care for Children
    • Financially assists IL families and Children with special healthcare needs
    • Acts as a secondary insurance and often covers what primary insurance doesn’t
    • Eligibility is determined by family income and  the diagnosis or needs of the child


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