Physical Therapy Insurance Info
Insurance 101 for Physical Therapy Patients
Understanding your physical therapy insurance coverage can be tricky. Just because your insurance "covers" physical therapy doesn't necessarily mean you won't have any out-of-pocket expenses. In many cases, you may still have to pay a deductible, co-insurance, or copayment. Let's break down some common physical therapy insurance questions to help you better understand your plan.
Key Terms in Insurance for Physical Therapy
What is a deductible?
This is the total amount you must pay out-of-pocket before your insurance for physical therapy starts to pay. For example, if your deductible is $1,000, your insurance won't pay anything until you've paid $1,000 for services subject to the deductible. Even after meeting your deductible, you may still owe a copay or co-insurance for each visit.
What is a copay?
This is a fixed amount you must pay for a covered service, as defined by your health plan. Copays usually vary for different plans and types of services. You must pay this amount at the time of service. In most cases, copayments go toward your deductible.
What is a coinsurance?
This type of out-of-pocket payment is calculated as a percent of the total allowed amount for a particular service. It's your share of the total cost. For example, if your plan's allowed amount for an office visit is $100, you've met your deductible, and you're responsible for a 20% coinsurance, you would pay $20 at the time of service.
Physical Therapy Insurance Questions About Medicare Part B
Medicare Part B patients are responsible for a 20% coinsurance, typically $20-25 per visit. If you have original Medicare as primary insurance and secondary insurance, the secondary payer becomes responsible for the 20%. Contact your secondary insurance carrier for specific details.
How much will I owe for each physical therapy visit?
If you haven't met your deductible, you'll pay out of pocket per visit until it's met. You'll then owe any applicable coinsurance or deductible balances after we receive the Explanation of Benefits (EOB) from your insurance company.
What if I can't afford frequent payments?
We prioritize your health and can arrange a payment plan that fits your budget, allowing you to pay for your care over a timeframe that works for you.
Important Notes About Insurance for Physical Therapy
- Insurance companies often offer multiple plans with varying benefits. Two patients with the same insurance provider may have different financial responsibilities.
- Use your insurance's online patient portal to check benefits, track your deductible, find in-network providers, and monitor claims.
Tips for Choosing an Insurance Plan with Physical Therapy Coverage
When selecting an insurance plan, consider these physical therapy insurance questions:
This is the monthly amount you pay for coverage. The lower it is, the higher your deductible will typically be. Plans with low premiums and high deductibles often are called “catastrophic” plans. Conversely, higher premium plans often feature lower deductibles, copays, and coinsurances.
This is the total amount you must pay each year before your insurance begins to pay. For example, if your deductible is $4,000, then you must pay $4,000 toward deductible-applicable services before your insurance will pay anything. If your deductible applies to PT services, then you may have to pay per visit until you meet your deductible. Once you reach your deductible, your copay or coinsurance will apply.
High copays are another common drawback to low-premium plans. Remember, the copay applies even after you have met your deductible, and the copay for specialist visits—including PT visits—can be as high as $80-$100. So, if you anticipate a lot of office visits during this plan year, you will want to factor the copay into your decision process.
As previously noted in this document, coinsurance is another version of cost-sharing. So, you will likely have to pay either a coinsurance or a copay. However, while copays are fixed amounts—and thus, are more predictable—coinsurances are percentages. Therefore, your financial responsibility varies based on how much your provider charges for the services rendered.
Some insurance plans (e.g., PPOs, HMOs, and EPOs) are limited to a certain network of providers. So, make sure you have a good selection of covered providers and facilities in your area. If you travel frequently or live in a rural area, you may want to choose a plan that has no network restrictions.
If your insurance plan requires you to obtain a referral before seeing a specialist (e.g., a physical therapist), and you fail to do so, the insurance company may (more than likely, will) deny coverage for services rendered. So, if you do not want to go through a primary care provider (e.g., your family physician) each time you want to see a specialist, make sure your plan does not require a referral (a.k.a. prescription) for specialist services.
Some plans place a limit on the number of covered visits per year (e.g., 20 visits), while others allow for unlimited visits. If you are athletic, have chronic joint pain, or anticipate needing a joint replacement in the near future, you may not want any restrictions on the number of rehabilitative visits allowed.
Medicare only pays 80% of the cost of care, so many Medicare beneficiaries seek secondary insurances to pay the other 20%. However, even those plans often feature deductibles, copays, coinsurances, or visit limitations. Thus, we recommend posing all of the above-listed questions to any secondary insurances you are considering.
The Bottom Line on Physical Therapy Insurance Coverage
Higher-premium plans generally benefit individuals expecting regular medical care. Lower-premium plans offer monthly savings but may not offset the cost-sharing portion for frequent care.
The Self-Pay Option for Physical Therapy
Yes! Please contact us and we will go over the details and pricing with you.
For more information about your specific physical therapy insurance coverage or to discuss any physical therapy insurance questions, please contact Integrated Physical Therapy at 305-967-8976.
