It is hard to believe it is almost Halloween, and in two busy, holiday-filled months, the year will be over.

So in the “spirit” of this spooky season, let’s turn our attention to some year-end issues of “grave” importance that can “creep” up on you and your clients, and cause “mischief” for even the best therapists:

1. As we near the end of the year, clients may hit their Out-of-Pocket (OOP) Maximum. The OOP Maximum is the cap, or limit, on the amount of money the client has to pay out of their pockets for covered services in any plan year. This amount varies depending on the client’s plan.

When the client reaches their OOP Maximum, claims will be paid in full by the health plan without a client copay or deductible taken out for the rest of the year. This means it is likely you will need to refund or credit any clients who paid copays for those sessions. So, at this time of year especially, closely examine your Explanation of Benefits, aka EOB – that document that tells you how each claim was processed – for any changes in the amount being paid for each session.

Keep in mind that some clients may never hit their yearly OOP Maximum. But some may reach it if the client or their family had significant health expenses that year. A client could reach their individual OOP Maximum OR their combined family expenses may use up their Family OOP Maximum. While the OOP Maximum will typically restart on January 1st, keep in mind that some plans do NOT restart on the first of each year.

2. In the next few weeks, your clients may be choosing their health plan for next year. It’s a good time to ask them if they intend to make changes in health plan company or type of plan. Educate yourself about different types of health plans available (PPO vs. HMO, etc.) so you can assist clients to understand their choices. For example, if they switch from a PPO to a HMO plan, they must see a provider in their HMO network to be covered.

While you don’t need to be an insurance expert, I believe basic healthcare education is an essential part of our job, and clients are usually grateful if you can help them “navigate the insurance maze.” At the very least, help with good questions to ask. Without guidance, clients often sign up for the plan with the cheapest premiums, without evaluating the coverage, or the copayments and deductibles they will have to pay.

Help them verify that your sessions will be covered by their new insurance plan. If not, you’ll need to discuss the cost of continuing treatment with you, or you may need to begin discussing a referral.

3. If you are not covered at all by the client’s new plan, one possible solution would be a Transition of Care (TOC) Agreement. If arranged, a TOC would mean you would sign a contract with the new insurance plan to provide a certain number of “transition” sessions JUST FOR THIS ONE CLIENT, even though you are not a network provider. The goal of the TOC is to give time to complete treatment or to transition the client to a network clinician. TOCs can often work out beautifully, but not always – read more here.

4. Clients enrolled in Medicaid or who get their insurance through a state Marketplace (also known as an “Exchange”) may be particularly vulnerable to insurance loss or changes. Due to changes in Medicaid programs, many clients will lose their Medicaid eligibility in 2026, and federal assistance for these plans will diminish in many states. Or your client may lose the Marketplace premium subsidies which have helped them to afford insurance in the past (these subsidy cuts were one of the big sticking points in the government shutdown battle).

A final tip: Remember that in January, you will need to contact your clients’ health plans (new or continuing) to check for changes in coverage – particularly copay amounts.