October 2021 - Kate Gegg, AM, LCSW

October 23, 2021March 27, 2023

Insurance Premiums and Deductibles

While I am not an insurance broker, I have come to see time and again how a lack of training on our complicated insurance system creates barriers to accessing care in the United States.
This is the second post in a multi-part series aimed to help you understand how American insurance works so that you can protect your finances and use your insurance benefits to help you access any and all medical treatment, including mental health treatment.
The first post covered the basics of insurance networks. Today we’ll cover the basics of insurance payments: Premiums and Deductibles.
Premiums: This is the “subscription” fee for your specific insurance plan for you and / or your family to be members of the plan. This gets paid directly to your insurance company. Premiums are usually paid monthly and can change from year to year.
If you get your insurance plan through your employer one of the big perks is that employers often contributes to the cost of the premium. You may pay $10 – $500 or more a month, and that still may only be a fraction of that “subscription” fee for your plan.
Deductible: A deductible is set amount you must pay towards your medical treatments before insurance kicks in and contributes to the cost of treatment moving forward. You pay your deductible to your medical providers. Deductibles reset annually, and the deductible amount can change from year to year.
For some services the “deductible is waived”, this means your insurance contributes to the cost of the medical service right away. For other services you will have to pay the deductible amount in medical care before your insurance plan contributes to the cost.
Often, plans with low premiums have high deductibles or other fees. This means you pay less every month as your set fee, but when you need to access care you may be on the hook for more.
So, you want to pay attention to your premium cost (this is how much you pay a month to have a membership to your plan) AND your deductible amount (this is how much you have to pay before your insurance starts contributing).
See today’s post for more information about types of deductibles, why insurance premiums can increase if you leave a job and go on COBRA, and for examples about how all of this works.

Generally speaking, premiums are straight forward when you think of them like a subscription fee. The only caveat to that is understanding what happens if you leave a job and want to access your insurance through COBRA.

When you leave a job in the US you are often eligible for COBRA. This means you can keep the same insurance plan for a period of time that you had at your company, but (unless your company agrees to continue contributing to your premium payments) you are responsible for the premium costs. Often premiums go WAY up if your company isn’t chipping in. This is because you were always only paying a fraction of the subscription fee and one of the perks of being an employee was the company’s contribution to the plan.

Deductibles are less straight forward given there are individual, family, in-network and out-of-network deductibles on most plans. First, let’s understand key language: Once you’ve paid for enough of your medical expenses to hit the magic number of your deductible it is considered “satisfied” or “met”.

Individual and family deductibles are aimed to protect a family from having to pay too much in medical expenses in any given year. The deductible is considered satisfied for all members when the family deductible is met, even if individual deductibles aren’t met. I know that’s confusing, there is an example in the comments (#4) that will help.

You may see that your in-network deductible is drastically lower than your out-of-network deductible. This is because your insurance company has a contract with in-network providers that outlines every possible medical service and how much the company will pay for that service. Your insurance company wants you to see these providers because they’ve vetted them, their credentials, and their training; and all parties have agreed in advance what the costs will be. If you see someone in-network you have to pick from the insurance company’s in-network provider list, but (often) it will cost you less. You can decide if its worth it to you for any given provider to see someone out-of-network.

Comments

I know this may seem unimportant, confusing and /or boring, but understanding how this works empowers you to select plans based on your medical need and can simultaneously help you protect your finances. Plans are usually selected once a year, so bookmark this and come back to it for a refresher when your plan is up for renewal.
Are you someone that wants the freedom to see whatever provider you choose? Look for a plan with excellent out of network benefits, then you protect your finances and can have freedom in selecting a provider.
See the first post in this series on in-network vs out-of-network for more information to help you understand american health insurance.
An example of meeting a $700 deductible: $10 for a prescription, $500 for a lab test, $190 for a medical appointment. That adds up to $700, meaning the deductible would be met. A key point: Not ALL types of medical expenses count towards meeting your deductible, again, this can be plan specific and is a good question for you to ask as you’re deciding what plan you want to be on.
Family vs individual deductibles explained through an example: Imagine a family of four, two parents, two kids. Each person could have an individual deductible of $700, and the family deductible could be $1400. That means once the family, as a cumulative unit has paid $1400 towards their deductible the deductible is considered met for all family members. Otherwise, it is met for each individual when they hit their individual deductible amount. Meaning if one kid hits $700 and one parent his $700 the deductible would be considered met for all family members, INCLUDING the two individuals that have not spent anything towards their deductible. Even if each member only hits $351 they would still have met the family deductible because they are over that $1400 family number. This is can create an incentive for family members to be on the same plan depending on the size of the family and the size of the deductibles.
Empower yourself by asking your HR department or insurance provider “what services are waived under the plan’s deductible” (translated into non-insurance speak, this means what services will be covered as though I’ve met the deductible even before i’ve met it). It’s not uncommon for preventive services to be covered including services like therapy!
If you’re planning to leave a company, ask your HR department about what the full premium costs are so you know what to expect if you’re planning to enroll in your plan through COBRA. You may also be able to negotiate the company continuing to cover a portion of your premium costs depending on the circumstances of your departure.
Have you ever heard horror stories about a provider or hospital charging someone $3,000 for a bandaid? The reason that can happen is because out of network providers / hospitals are entitled to charge whatever they want. In-network providers are the only providers bound by a contact with the insurance company that limits how much they can charge to the patient.
Be aware, there are insurance nightmare stories out there about certain labs / facilities / providers not being in-network, and patients not being notified in advance that they will be accessing an OUT of network lab from an otherwise IN network provider or hospital. This is something to discuss with your provider in advance to make sure they use external labs or other providers that accept your plan.
You may be asking yourself why would I see an in-network provider if I have a high deductible because I will be paying anyway. Good question. The advantage of seeing an in-network provider even if you have a high in-network deductible is that even though you are paying in full, your insurance has capped how much your provider can charge you. If you see an out of network provider the insurance company has no influence over what the provider charges, and it’s often more than the rate an in-network provider will be allowed to charge (see comment above on the $3000 bandaid).
How do HMOs and PPOs and POS etc fit into this? Essentially HMOs are small “in-network” plans and “PPOs and POS’s” are large “in-network plans”. With most HMOs you have to get a referral from your primary care physician to see anyone else and have insurance cover it, but that too depends on the plan. With PPOs you don’t need a referral but “in-network” and “out of network” still applies.
What about medicaid and medicare? Same thing applies, some providers and facilities accept medicaid and medicare and others don’t.

October 17, 2021March 27, 2023

Displacement

Our feelings are harder to access in environments where they are not welcome. This can be with certain people who we feel shut us down, and it can also be with our internal world if we believe certain feelings are bad, unproductive, or unacceptable.
When we can’t access and process through our feelings directly we may find ourselves prone to using displacement. When we “displace” we focus our energy, attention, and conversation around something other than the core issue at hand.
Displacement can be an indirect way of addressing an emotionally charged / intense topic or a topic we can’t find an accessible entry point into discussing or feeling our way through.
Example: you’ve had a bad day at work and take out your anger on your family once you’re home. Perhaps you’re feeling angry about work, and simultaneously feeling like you can’t change that environment / express yourself there and maintain professionalism (i.e. you can’t find an accessible entry point at work to handle your concerns in a direct way).
Although you don’t want to be irritable at home, you may (consciously or unconsciously) rationalize to yourself that your family is “stuck with you” and so you release your frustrations at home. In this scenario the person has displaced their anger at work onto their family members and in an environment where they feel their negative emotions are more tolerated.
Sometimes displacement of this nature can happen even when we don’t consciously *feel* angry. So yes, this means you can have a feeling, not register that you are having it, and then direct a release of it toward some other topic or person in your life.
The trouble with displacement is we focus our attention, energy, and conversation around the focal point, at times without acknowledgement or awareness of the underlying issue(s) at hand.
Unfortunately, even if we can “resolve” the displaced issue (in this example the conflict with our family), we haven’t resolved the core issue (work) and the recipient(s) of our displacement often leave the interaction(s) feeling like the other has been unreasonable.
If we are regularly displacing in our lives we run the risk of resentment in relationships, having the same fight repeatedly, believing our internal world is unreasonable, and feeling confused by or untrustworthy of our reactions.
More in today’s post and comments about how displacement can creep into relationships and decrease our ability to solve problems in our lives. Also, tips for how to find displacement and what to do about it.

When we “displace” we focus our thoughts, communications and/or reactions to a “stand-in” person / object / situation as opposed to the actual person / situation we are having a reaction to. When someone says they feel treated like a punching bag, often they are describing being the recipient of someone else’s displaced feelings.

Displacement can happen in lots of ways, imagine you and your spouse are in a fight about how the dishes are loaded in the dishwasher. More often then not those types of fights are a displacement of a different, larger, and more emotionally overwhelming topic. Instead of facing that topic head on, we can displace onto something more accessible and concrete, like how the dishes are loaded. In this scenario the intense emotions about a larger dynamic (could be anything, perhaps how heard one party feels) are displaced onto a smaller dynamic (how the dishes are loaded) that comes to represent the larger one.

Sometimes we can displace as a way of protecting ourselves from feelings we don’t want to have or believe we shouldn’t be having. At those times we can be fully wedded the the notion that we are having reactions to “the dishes” rather than some larger problem we don’t want to be true of our relationship or in our lives.

Other times when we displace, we may feel aware that the strength of our reaction doesn’t totally make sense. A helpful way to get to core of an issue when you suspect displacement is at play in yourself or others is to ask (in a collaborative, non-judgmental, and accepting manner):

Can you articulate why there is so much emotion or heat around this topic?
Does it feel like this type of thing happens in other ways we may not be discussing?
What else happened today or recently that this reminds me of that I might also be having a reaction to?
Does it feel like we might really be talking about something or someone else here?

Until we can get to the core of the issues we face we are at risk of having the same underlying concern or conflict around “stand-in” topics. With curiosity and introspection we can work to understand and know ourselves better to catch displacement in the act, and get to addressing core underlying concerns.

Notes

One of the reasons that therapy is effective is that a skilled therapist provides a space for someone to feel their feelings without judgment. The relationship becomes a safe place to release your emotions, and it’s not uncommon for patients to find themselves surprised by what comes out in a session. If this has happened to you in treatment this is often a great sign that you feel safe in your relationship with your therapist and they are helping you access, process through, and release what is already there and needs room to come out.
Once we’ve gotten good at recognizing the signs of displacement in ourselves and can recognize when we’re displacing from one topic to another the displaced topic itself can become a helpful entry point into conversation. For example, “I’m noticing myself feeling angry about the dishes but as I think about it, I’m realizing it’s not just the dishes, it’s more that the dishes are one example of how I feel like I ask you to do something and it doesn’t happen. I think we really need to talk about this because I can tell I’m getting resentful”.
Affairs in relationships can happen for many reasons, but one avenue for thinking about them (and there are many others) is through the notion of displacement. If you are having an affair one of many questions you can ask to build introspection and awareness is what need aren’t you getting met from your partner or your life that you have displaced into this other relationship?
I mention in the post that sometimes we can feel like our reactions don’t totally make sense for the situation we are in. Sometimes this is because we are displacing, but all feelings are valid even if they are about numerous situations at the same time. See this post on the cumulative nature of emotions as well as this post on how our brains make associations for a deeper dive into that topic.
I mention in the post that our feelings are harder to access in environments where they are not welcome including our internal world if we believe certain feelings are bad, unproductive, or unacceptable. See more here for how to approach your internal world in a way that won’t shut it down .
I mention in the post that we can have an emotion and not register we are having it. It’s true. For more about how this works see this post on emotional blocking.
Alcoholics Anonymous groups talk about displacement too, though they use the phrase “Coming out Sideways” to discuss how emotions or reactions can come out “sideways” to a focal point other than the core issue, problem, concern, or person.
Our insight into our use of displacement can vary even if we are otherwise self-aware and reflective. We can be very self-aware in some categories of our life and in some relationships, as less so in others. Further, we can displace more around certain types of issues than others. Our insight can vary based on a variety of factors including whether we’re in our window of tolerance, or when we’re operating outside of our limits.

October 4, 2021March 27, 2023

Primary and Secondary Emotions

Our emotions, when they are heightened, can feel like a freight train, plowing through and interrupting everything in their tracks.
Often this is because, like cars on a freight train, emotions and thoughts are pouring in rapid fire one after another with no end in sight.
An example: you feel angry for a moment, but then, perhaps you feel guilty for feeling angry (or expressing it). Perhaps that can lead to frustration that you feel guilty. So on and so forth.
Some of us have a hard time identifying what our feelings are, or labeling them into categories like “anger”, “guilt”, or “frustration”. Instead we just feel revved up or activated or (at the other end of the spectrum) numb or flat.
In the DBT world Marsha Linehan describes primary and secondary emotions to help us begin to make sense of our inner world. Primary emotions are responses to our external world (like events around you or the actions of others). Secondary emotions are responses to our internal world (i.e. emotions in response to our emotions or thoughts).
For most of us, secondary emotions are the ones that cause the most upheaval and distress.
That’s because we can have many secondary emotions and they often come in quickly and more powerfully than the primary emotion that preceded it.
Secondary emotions often have a judgment built into them (i.e. I noticed I’m angry, but I feel like I shouldn’t be angry, so now I feel ashamed about my anger).
This can leave us in a trap where our emotions are loud, overwhelming, hard to distinguish from one another, and subsequently hard to resolve – even if we’re really trying. Instead we can feel out of control spinning and cycling, often in ways that interfere with our ability to be present in our lives.

For us to manage our emotional world we need to know what we are feeling and how to take care of ourselves in response to that feeling. An essential skill to help us regulate (balance) our emotional world is learning how to feel and process through emotions in a way resolves them.

There are many tools for managing your emotions, but one way to help you through them is to learn how to identify them. Once we’ve identified them, we often feel better because our internal world feels organized and less chaotic by our awareness of what’s happening within it. This is similar to strategic problem solving, usually the first step in a problem solving strategy is identifying what the issue is so you can address what needs resolution. The concept of Primary and Secondary emotions from Dialectical Behavior Therapy gives us a helpful starting point to do this in our emotional world.

Primary emotions are reactions to events in your external environment (being angry at someone for criticizing, feeling happy that a loved one is coming to visit etc). Secondary emotions are are reactions to your internal world (i.e. your thoughts and feelings). For example: feeling guilty when you feel angry or feeling pride in your ability to be happy for someone else.

Secondary emotions tend to cause the most distress for a few reasons:

1. They can be set off in a long overwhelming string (which I call emotional chaining), with numerous thoughts and feelings coming from and leading to one another.

2. They can dilute, overwhelm, and drown out the primary emotion making it difficult to identify and resolve whatever set that off. This overpowering often leaves us confused, potentially upset with ourselves, and overwhelmed.

3. If we have judged ourselves for experiencing our primary emotion (i.e. I got angry, but feel like I shouldn’t have gotten angry), we will both be stuck with our feeling and our belief that we shouldn’t have it; a complete trap to effective resolution of what’s happening.

To increase your ability to manage your emotions, start working to identify “primary” and “secondary” emotions. Look out for the three traps listed above and see notes for more resources.

Notes:

This post references material from Marsha Linehan’s emotion regulation module in her Dialectical Behavior Therapy treatment manual, specifically pages 86 and 89 of the manual. Full Citation: Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
If you struggle with secondary emotion trap number 1 (emotional chaining) and number 2 (secondary emotions overwhelming primary emotions) you want to work to help slow down your internal world so it doesn’t move quite as rapid fire. Working on staying in the present hugely helps here. There will be additional posts to come on this, but see this post on meditation for something you can start today.
If you struggle with secondary emotion trap number 3, (judgments), see these prior posts for help with tools and concepts to decrease the power of judgments; and this series on identifying, understanding, and challenging judgments.
Knowing how to manage emotions is a complex skill, sometimes we need to let ourselves ride them out, sometimes we need to pull away from them, sometimes we need to actively manage them. There will be many more posts to come on this topic but these previous posts on controlling our attention and knowing which types of coping skills to use when have helpful content.
Today’s post assumes you buy in that all feelings are worth having. Perhaps you don’t. This post covers some of the many reasons we want to keep both our positive and our negative emotions around.
Sometimes our emotions are too big or feel too far away for us to tolerate feeling through them. This happens when we are outside our window of tolerance. If this is the case you want to work towards grounding to help turn the dial down on the intensity (or the numbness) before working on feeling through.
This is similar, but not to be confused with behavioral chaining, a DBT technique in which you look back at each moment that lead up to a particular behavior to identify the feeling or experience that started the behavior.