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Understanding if Rula accepts your insurance

Navigating insurance can be daunting.  It can be helpful to have insight into some of the insurance intricacies that you might encounter. This article will address some common questions regarding the following topics:

Insurance Complexities

Understanding insurance benefits can be challenging. From mental health carve outs to the nuances of telehealth benefits, the complexities of insurance plans can leave many feeling overwhelmed.  Some items that add complexity.

 

Mental Health Carve outs

One of the most significant complexities in insurance revolves around carve outs. Many insurance plans include what are known as "carve outs" for mental health services. This means that mental health benefits may be administered separately from other medical services, leading to differences in coverage and reimbursement. Understanding these carve outs is crucial for individuals seeking mental health support, as they can impact access to care and out-of-pocket costs.

  • An example of a big carve out is for Blue Shield of California (BSC).  ~60% of all BSC members have a carveout for mental health benefits to Magellan.  Meaning an entirely different organization handles these claims.  And while Rula is in-network with BSC - we are not in-network with Magellan, so Rula is considered out of network for these plans with a carve out to Magellan.

 

Telehealth vs. In-Person Benefits 

The rise of telehealth has introduced new layers of complexity to insurance coverage. While many insurance plans now offer telehealth benefits, the extent of coverage can vary widely. 

 

Some plans may fully cover telehealth visits, while others may require copayments, only cover certain types of telehealth services, or require telehealth services to be performed by a specific vendor. Additionally, coverage for telehealth services may differ from coverage for in-person visits, further complicating matters for individuals navigating their insurance benefits.

Halcyon Carve Out

This carve-out is common if you have Blue Shield of California as your medical insurance provider. Rula does not currently have a contract with Halcyon, so an out-of-network benefits email would be received in this case. 

 

Healthworks Carve Out

This carve-out is common if you have Blue Shield of California as your medical insurance provider. Rula does not currently have a contract with Healthworks, so an out-of-network benefits email would be received in this case. 

 

Medicare / Medicaid Plans

There are several Medicare and Medicaid plan types. Some plans are “Medicare Advantage Plans,” meaning the patient has an insurance card for Medicare coverage through another administrator outside of traditional (aka original or straight) Medicare, but Medicare guidelines would still apply.

  • Examples of Medicare Advantage plans include Aetna Medicare Advantage, Anthem Medicare Advantage, Blue Cross and/or Blue Shield, Kaiser Permanente Medicare Advantage, United Healthcare Medicare Advantage.

  • Examples of Medicaid plans include Amerigroup, HealthNet Medi-Cal, State Medicaid. 

Note: Dual Eligible Beneficiaries are enrolled in both Medicare as primary and Medicaid as secondary coverage.

What's in-network at Rula

Medicare Advantage

Currently, Rula only accepts Medicare Advantage coverage from the following patient populations:

  • California
    • Kaiser Permanente (Southern CA)
    • Anthem Blue Cross
    • Carelon
    • Cedars- Sinai (assuming risk on behalf of Blue Shield 65 HMO)
    • OptumCare (assuming risk on behalf of various MA plans)
    • PIH Health (assuming risk on behalf of various MA plans)

  • Georgia
    • Anthem Blue Cross and Blue Shield of Georgia
  • North Carolina
    • Blue Cross and Blue Shield of North Carolina
  • Hawaii
    • Kaiser Permanante (Medicare Advantage and Medicaid)

At this time, we do not currently accept other Medicaid, Medicare, or out-of-network plans.


Rula's automatic verification of benefits (VOB) - how we help

At Rula, we are proponents of transparent information and we help to navigate the complex insurance landscape. As such we automatically verify a client’s healthcare coverage and financial responsibilities at the time of registration.

 

What is Verification of Benefits?

Verification of benefits is the process of confirming your insurance coverage details with your insurance provider. 

This process involves obtaining information such as insurance policy details, coverage limits, deductibles, copayments, coinsurance rates, and any other relevant information that may impact the patient's financial responsibility for healthcare services.


Key Steps in Our Verification of Benefits Process:

  • Gathering Patient Information: When a patient schedules an appointment or seeks services at Rula, our registration process collects insurance information (e.g., policy number, plan).

  • Contacting the Insurance Provider: Our systems automatically verify your insurance coverage and benefits at the time of registration. Patients will then see the below screen to confirm if they are in network.

    AVOB confirmed screen with email.png

  • Determining In-Network Status: We can determine whether your insurance plan is accepted as an in-network provider at Rula within 8 seconds. Being in-network typically means that we have a contracted agreement with the insurance company, which may result in lower out-of-pocket costs for the patient.

  • Estimating Patient Liability: Based on the information obtained during the verification of benefits process, we estimate the patient's financial responsibility for the services they receive. This may include deductibles, copayments, and coinsurance. Patients will be emailed this detailed estimate after they complete the registration process.

 

Important Disclaimer of Rula’s Verification of Benefits:

It's important to note that estimates provided during the verification of benefits process are just that—estimates. Insurance coverage can be complex, and actual costs may vary. Therefore, confirming benefits directly with your insurance plan is also beneficial.


If you have questions about our VOB process or the results you received feel free to also contact us at support@rula.com.

Referrals vs authorizations

When it comes to accessing healthcare services, it's important to understand the difference between referrals and authorizations, as they serve distinct purposes and have different implications for your coverage and out-of-pocket costs.

  • Referral: A referral is a recommendation or order from your primary care physician (PCP) for you to see a specialist or receive certain medical services from another provider. Referrals are typically required in Health Maintenance Organization (HMO) plans and some Point of Service (POS) plans before you can receive care from anyone other than your PCP.

  • Authorization: An authorization, also known as a prior authorization, is a formal approval from your insurance company before you receive certain medical services, treatments, or prescriptions.  Typically, authorization will have limits based on time and number of visits.

While in most cases referral and authorizations are not required for mental health services - some plans still require them. Failing to obtain the necessary referrals or authorizations can result in higher out-of-pocket costs or even a denial of coverage.  

  • If you are unsure if you need a referral or authorization for outpatient mental health services it is best to contact your insurance.

Kaiser authorization process

At Rula we are pleased to work with Kaiser patients - however, they have a known referral / authorization protocol.  In short, clients must obtain authorization for treatment from Kaiser prior to starting care with a Rula provider.  If you have not obtained an authorization, please reach out to your PCP or Kaiser’s authorization department to obtain one in order to prevent issues with claims processing and unexpected patient responsibility.  


Additional information regarding coverage with Kaiser and Rula can be found in the section below.

 

Kaiser Insurance Overview

Rula is very excited to be partnering with Kaiser Permanente in Southern California and Hawaii! This article reviews the two Kaiser Permanente insurance plans Rula accepts, and additional details regarding the Initial Authorization  Information. It also includes important details on out-of-pocket costsposts with Kaiser insurance and specific plan details such as Kaiser Permanente HMO, Kaiser Permanente DHMO, and Kaiser Permanente Medicare and Medi-Cal.

Kaiser Permanente insurance plans Rula accepts

  • Kaiser Permanente Southern California
  • Kaiser Permanente Hawaii

Kaiser Initial Authorization Information

Kaiser Permanente provides patients with a letter that indicates the patient has an initial 6 or 12-month authorization  for up to 16 sessions for those with Kaiser Permanente Southern California insurance and up to 52 sessions for patients with Kaiser Permanente Hawaii insurance. 

  • If a patient needs additional sessions beyond the initial authorization, Rula will coordinate with their therapist to obtain an additional authorization from Kaiser if ongoing care is needed.

 

Requesting additional referrals or visits

When additional sessions are determined to be medically necessary beyond the number of visits covered by the initial Kaiser referral, Rula can obtain a new referral from Kaiser, pending a Clinical Care Review (CCR), to ensure continuity of care in treatment for clients who need ongoing services.

  • Existing Rula patients should discuss with their therapist whether ongoing care (additional visits) are medically necessary. 
  • Existing patients should not reach out to Kaiser directly to receive an additional referral. It is important to note that a client will remain in care as long as it is deemed medically necessary following a Clinical Care Review.

If additional sessions are not deemed medically necessary, patients will coordinate discharge from care with their therapist. The therapist will provide Kaiser members with aftercare resources. 

 

Understanding out-of-pocket costs with Kaiser insurance

For patients with Kaiser Permanente Southern California coverage, copays for virtual visits are $0, but we will check your coverage and confirm your out-of-pocket cost before scheduling your first session. 

  • Some plans have a deductible that applies to mental health services, and the deductible will need to be met before Kaiser covers your visits in full.

Patients with Kaiser Permanente Hawaii coverage may have a copay or deductible that applies for virtual visits.

We will provide you with an estimate of your individual benefits to better understand your insurance and plan for your costs of care. You may also contact Kaiser directly to confirm your expected out-of-pocket costs.

 

Kaiser Permanente HMO

Expected costs of visits should always be verified with your insurance provider and the following represents expected costs and cannot be guaranteed.

  • Rula sessions can be covered by Kaiser Permanente HMO plans for Kaiser Permanente Southern California and Kaiser Permanente Hawaii patients only. 
  • Patients with HMO plan types have no annual deductible, no coinsurance cost, and no copay. We estimate your per-session cost to be $0. 
  • If you would like a more accurate estimate regarding your deductible and session cost, please contact Kaiser directly.

 

Kaiser Permanente DHMO

Expected costs of visits should always be verified with your insurance provider and the below represents expected costs and cannot be guaranteed. 

  • Rula sessions are covered by Kaiser Permanente HMO plans for Kaiser Permanente Southern California and Kaiser Permanente Hawaii patients only. 
  • Patients with DHMO plan types have a $0 copay. However, you may have a deductible you need to meet before the total session cost is $0. Until your deductible is met, the session cost will vary. 
  • If you would like a more accurate estimate regarding your deductible and session cost, please contact Kaiser directly.

 

Kaiser Permanente Medicare and Medi-Cal

Currently, Rula participates in Kaiser SoCal's Medicare Advantage plan and Kaiser Hawaii's Medicaid plan for therapy only. Kaiser Hawaii Medicare Advantage is out-of-network and will not be covered by your insurance. 

 

Does Rula do out-of-network billing?

We do not bill out-of-network insurance companies for services rendered at Rula. However, this does not mean you cannot receive care if you have out-of-network coverage.  

 

If you have out-of-network insurance coverage or if we do not participate with your insurance plan, you can still receive care from a Rula provider using our self-pay (cash pay) option. This means you pay for the services at the time of your appointment.

 

Superbills

Upon request, we can provide you with a detailed invoice called a superbill that outlines the services you received and the amount you paid. You can submit this superbill to your insurance company for potential reimbursement of out-of-network benefits. 

Please note that reimbursement is subject to your insurance plan's policies and coverage.

 

Understanding your out-of-network status

Navigating insurance terms and processes can often be complex, especially when trying to understand why your mental health provider or service appears as in-network but results in out-of-network status. This guide simplifies these terms and empowers you with clear, comprehensive information, helping you make informed decisions about your mental health care.

What Do In-Network and Out-of-Network Mean?

  • In-Network (INN): Healthcare providers or facilities that have a contract with your insurance company to provide services at an agreed-upon rate, generally resulting in lower costs for you. In short, this means that your insurance will cover services.

  • Out-of-Network (OON): There are many possibilities why your insurance might come up as out-of-network, with some of the most common reasons listed further on in the article.

If your insurance comes back as out-of-network, you still have some options! You can enroll in our self-pay rates of $150 for individuals and $165 for family/couples per 60-minute therapy session. 

You may still be able to use out-of-network benefits.  To do so, we always recommend calling your insurance company directly using the information on the back of your insurance card to get the most accurate information regarding these benefits and the process to file out-of-network claims with them. 

  • Please note that submitting out-of-network claims will be the patient’s responsibility, as Rula currently does not bill for out-of-network services. 

Why does Rula advertise as in-network with my insurance carrier, and I get an out-of-network status afterward? 

 

Rula is proud to work with most major insurance companies and is frequently expanding our insurance carrier network! 

Insurance, however, can be complex. While we may be in-network with an insurance company, different factors can affect eligibility and coverage status. Due to this, Rula conducts a Verification of Benefits (VOB) before your initial visit. After the VOB is completed, you will be provided confirmation of your coverage status (INN/OON) and an estimate of your visit costs.

In the next section, we will list the most common reasons why you may get an Out-of-Network notification. 

 

Common Out-of-Network Reasons 

Insurance coverage is not always straightforward and has many layered factors that affect whether your Rula sessions are considered In-Network or Out-of-Network services. 

Below, we outline some of the most common reasons you may get an Out-of-Network status: 

  • Plan-Type Details: Insurance plan types vary greatly, even within the same insurance company. Some examples include PPO (Preferred Provider Organizations), HMO (Health Maintenance Organizations), or EPO (Exclusive Provider Organizations) plans. While Rula may be contracted to accept one plan, we may not be contracted for another plan type.

  • State Location Variations: Rula’s network status may vary by state or region, affecting whether services are considered in-network or out-of-network. Your plan may also have region limitations, meaning you’re only able to seek in-network care in specific counties or regions.
  • Insurance Carve-Outs: Certain services or types of care, especially mental health, may be carved out of the standard insurance agreement and managed under different networks. These carve-outs can affect whether a service is covered as INN or OON, depending if Rula has a contract with the carved out network. 

  • Recent Changes in Insurance Contracts: Contracts between Rula and insurance companies can change. Updating an agreement after your last benefits check could affect whether providers are considered INN or OON.
  • Specific Provider Credentialing: While Rula may be contracted with your insurance company and plan, individual providers may not be credentialed with certain insurance companies or plans. If a provider is not credentialed to accept specific insurance company or plan, they will be considered out-of-network and cannot bill your insurance for services rendered. In these cases, you still have options! 
    • You can select a new provider credentialed with your insurance and use your In-Network insurance benefits. 
    • If you prefer to continue with your current mental health provider, you would be responsible to pay our self-pay rates. 
      • Individual Sessions: $150
      • Couple and Family Sessions: $165 

We always recommend contacting your insurance company to confirm your mental health benefits to ensure accurate billing information throughout your time at Rula. 

  • Inactive Insurance Coverage: If your insurance plan is found to not be active during the VOB process, you may receive an OON notification. [when we run benefits, active when the VOB is being run, if provided early then it will come back as OON/not effective or active]. 

What can I do if I receive an Out-of-Network notification?

  • Reach out to your Insurance Provider: We always recommend contacting your insurance provider to confirm if you have out-of-network benefits and to understand the specifics of your plan. You can locate the member services phone number on the back of your ID card to call your insurance.

  • Keep Your Information Updated: Make sure your insurance details are current in our system. Update any changes through your patient portal or contact our support team for help.

Ask for Help: If you find discrepancies or have questions, our dedicated support team is here to assist you. Don't hesitate to ask for clarification about your coverage status or other concerns.

 

Self-pay (cash pay), not using insurance

Self-pay (cash pay) refers to patients who choose to pay for healthcare services out-of-pocket, without relying on insurance coverage or billing. This option provides flexibility and accessibility to individuals who may not have insurance or who prefer to pay directly for their care.

If we are out-of-network with your insurance or you choose to pay out-of-pocket for your care your costs will be:

  • Therapy services: $150 for individuals and $165 for family/couples per 60-minute therapy session
  • Psych/med management services: $150 initial, $150 follow-up/subsequent

 

PAR vs. Non-PAR provider

The terms "PAR" and "Non-PAR" are often used in the context of healthcare, particularly in relation to health insurance and medical providers. 

Here's what each term generally refers to:

PAR (Preferred Provider):

  • A PAR provider is a healthcare provider (such as a therapist, doctor, hospital, or other healthcare facility) that has a contract with a specific health insurance plan or network.
  • When a provider is PAR with an insurance plan, it means they have agreed to accept the insurance plan's approved amount (also known as the negotiated rate) for covered services.
  • Typically, this results in lower out-of-pocket costs for patients who are members of that insurance plan, because the insurance plan will pay a higher percentage of the cost when services are received from a PAR provider.
  • PAR providers may also handle billing and claims submission directly to the insurance company on behalf of the patient.

Non-PAR (Non-Preferred Provider):

  • A non-PAR provider, on the other hand, does not have a contract with a particular insurance plan or network.
  • Patients can still choose to see non-PAR providers, but the cost-sharing arrangement and coverage may differ.
  • When patients receive services from non-PAR providers, they may be responsible for a higher percentage of the costs, because these providers do not have negotiated rates with the insurance plan.
  • Patients might also need to pay the full amount upfront and then seek reimbursement from their insurance company themselves.

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