For many people, physical therapy is a critical component of their medical care, whether it’s to recover from an injury or prevent degenerative conditions from worsening. Unfortunately, the effectiveness and importance of physical therapy don’t always mean it is affordable, and many Americans will have to rely on their insurance provider to be able to access this care. It can sometimes be difficult to understand what exactly your plan covers and how much you may owe for physical therapy. While the answer is different for everybody, there are some questions you can ask to determine what this coverage may look like for you.
Any health insurance plan that is compliant with the Affordable Care Act (ACA) and other state-marketplace regulations is required to offer ten “essential benefits.” By law, these plans must cover anything that counts as one of these ten benefits. One of these categories is rehabilitative services, which can include physical therapy. In addition to these plans, any federally qualified HMO plan should cover physical therapy.
When it comes to other private insurance, there are three possible scenarios: physical therapy is covered with a co-pay from you, physical therapy is covered and you pay a co-insurance and/or deductible, or physical therapy isn’t covered and you will have to pay out of pocket. In some cases, which scenario applies to you will depend on the reason for your physical therapy.
For example, your plan may not cover physical therapy as a preventative treatment related to athletic endeavors, but it may cover the service if you are recovering from surgery.
Health insurance plans can be difficult to understand. Before you begin any treatment, it’s a good idea to reach out to your insurance provider for clarity on what exactly your coverage will look like. This can help you avoid surprise bills or even a denied claim.
Insurance companies contract with specific providers to agree upon rates. An in-network doctor will be covered by your insurance, while an out-of-network provider may have less or no coverage at all. You’ll want to be sure that the provider you choose is covered under your plan before beginning treatment. If you choose to go out of network, ask what the rates look like in that scenario.
Many plans have a lifetime maximum, annual maximum, or maximum amount they will pay per condition. Ask what this amount is and what it will look like if you need PT for another reason in the future.
Insurance plans have something called a deductible, which is the amount you are responsible for before coverage kicks in. You should understand what your deductible is, if physical therapy is subject to it, how much is left until you reach it, and what will be covered before and after you hit that number.
In addition to this, do you have an an out-of-pocket maximum? An out-of-pocket maximum accounts for your deductible as well as co-pays or co-insurance that you may pay. Find out what happens if you have one, what it is and what happens when you reach this limit and what it is.
Some plans limit the number of times you can see a certain provider for a certain condition. You should ask if such a limit exists for physical therapy.
Part of physical therapy can be the use of assistive devices in your life outside of sessions. Some plans may cover your sessions, but not this equipment. Before you buy anything, you should find out if you would be reimbursed or not.
When seeing a specialist like a Canton, GA physical therapist, some insurance will require a referral from a primary care physician to demonstrate medical need. If you do need a referral, this should be documented before you begin any treatment.
In most cases, there will be at least some amount you pay out of pocket for physical therapy, even if it is just co-pays. Some people will have large deductibles and high out-of-pocket costs in order to get the treatment they need.
One way to help with these costs is to use an HSA or FSA. These savings accounts are funded pre-tax, with the money designated for use on medical expenses. As long as a doctor prescribes physical therapy, you can use these savings to pay for the services.
Before you begin any treatment, speak with both your insurance company and the provider’s office to fully understand the financial implications and work out a plan for payment. Physical therapy is worth the effort of working out these financial concerns early.
