Is There Coverage for Physical Therapy Under Your Insurance Plan?

Is There Coverage for Physical Therapy Under Your Insurance Plan?

Here Are Some Questions You Should Have Regarding Physical Therapy and Your Insurance Coverage.

In a lot of different health regimens, physical therapy is an essential component. There are numerous scenarios in which a medical professional may conclude that you are in need of physical therapy, sometimes known as PT. 

It’s possible that you’ve recently undergone surgery or have been dealing with an injury. It’s also possible that you have a preexisting condition that can be helped with physical therapy.

However, the expense of physical therapy can build up over time. It is highly likely that you may require more than one session, which may be spread out over a period of several weeks or months. You will be required to make a financial contribution for each of these treatments. 

For instance, the price of one session of physical therapy following rotator cuff surgery might range anywhere from $50 to $350 per appointment. If the therapy is covered by your health insurance, the only costs you may be responsible for are the deductible, copayment, and coinsurance. 

Nevertheless, these things can add up. Many individuals require up to 36 sessions of physical therapy in order to regain their normal range of motion. It may be challenging to cover these fees using one’s own resources. 

Physical therapy is covered by a lot of different insurance policies. However, in order for the sessions to be covered, they must be considered an “essential benefit.” This can include:

  • Services are geared toward health maintenance and prevention.
  • Taking care of an illness that is chronic
  • Services include both rehabilitation and habilitation.

If the treatment that your physician recommends is not considered an essential benefit, then it is possible that it will not be covered. You need to make sure that physical therapy sessions are covered by your health insurance before you start attending them. 

You will also want to find out what percentage of the cost your plan will cover because it is possible that it will only pay for a portion of the whole cost. In order to find out, ask yourself these important questions.

Is your insurance plan going to cover the cost of physical therapy?

Health insurance policies that comply with the Affordable Care Act (ACA) and state-marketplace policies provide 10 “essential benefits.” These plans are required by law to provide coverage for everything that can be counted as one of these benefits. 

This does not imply that purchasing insurance through the marketplace is required in order to have coverage for physical therapy. Your physical therapy ought to be covered if you have a federally qualified HMO plan through your place of employment. 

 Your insurance company will, in the vast majority of instances, tell you one of the following three things:

  • You will be responsible for paying the rate that was agreed upon between your insurance and the physical therapist. PT is not covered.
  • PT is included in this: The term “coinsurance” refers to the portion of the charge that is paid by your insurer.
  • PT is included in this: Your payment for the appointment is referred to as a “copay,” and it is a set rate.

Additionally, certain preventative physical treatments might be paid for by the insurance company. This indicates that it reduces the likelihood of sustaining an injury or becoming ill as a result. Your plan may, for instance, provide coverage for physical therapy that reduces the risk of falls among elderly people who reside in a community setting. 

There is a possibility that PT is not covered by any of the short-term health insurance policies or other non-ACA compliant plans.

Concerning Some Questions Regarding Your Health Insurance Regarding the PT Coverage

Always check with your health insurance provider first before getting treatment of any kind. You will need to verify with them that coverage will be provided for your physical therapy sessions. If you don’t want your claim to be denied or you to have to pay fees you didn’t expect, you should ask more questions.

Most health insurance policies will pay the cost of having it performed by a qualified physical therapist if it is determined to be habilitative or rehabilitative in nature and deemed medically necessary. 

This indicates that you might be required to have a statement on your medical file from the office of your physician declaring that you require physical therapy. The requirements may be different from one state to the next.

Is There a Cap on the Amount of Money That Will Be Paid by Your Insurer for Your PT?

Inquire about the maximum allowed for a lifetime, the annual amount, or the “per-condition” limit. For instance, if you got injured while running in March, you might need to go to physical therapy. After that, in July, you can damage your back again and require further PT.

What happens if you need to go to physical therapy more than once a year? Does it make a difference whether it’s for the same issue or two completely separate ones? Will there be a single restriction, or will there be different limits for each condition?

Do You Have to Go to a Physical Therapist Who Is Part of Your Network?

There is no single physical therapist who is ideal for treating each and every patient. Some people concentrate their efforts on treating particular conditions or injuries. It’s possible that the therapy you require can only be provided by a specialist who is not part of your network of providers. 

Inquire about any additional prices or coverage restrictions that may apply if you venture outside of the network. When compared to the cost of in-network care, this is significantly lower. 

In the event that you are having problems locating a therapist who is part of your network, you could inquire about referrals from your primary care physician. They might be able to assist you in finding the person you’re looking for.

Is There a Deductible with This Policy?

It’s possible that your insurer will pay for some or all of your physical therapy expenses straight away. It’s also possible that they won’t help until after your deductible has been met. If you are aware of which one will occur in advance, you will be better able to arrange your finances.

Is There a Cap on the Amount That Can Be Paid Out of Pocket?

A maximum amount that you are responsible for paying out of pocket can help you save money if you go through a lot of physical therapy. This cap is the most that can be demanded of you on an annual basis. 

In the event that you reach your out-of-pocket maximum, you may be eligible for full coverage of any additional physical therapy. This often depends on what the rest of your health insurance plan covers.

Is There a Cap on the Number of Physical Therapy Sessions That Can Be Performed or a Time Limit?

Some plans may restrict the services that you can receive for the first thirty to ninety days that you have the plan. It’s possible that this will prevent you from receiving the therapy you require. 

If this is the case, you should consult with your primary care physician. They might be able to get in touch with your insurance company and get a waiver for treatment that can’t wait.

Does Your Plan Offer Protection for Equipment and Other Devices?

It’s possible that your physical therapist will recommend that you complete some of your therapy or exercises at home in order to speed up your recovery. It’s possible that some of these are easy to carry out. It’s possible that some people require specialized gear.

It’s possible that your visits will be covered by some plans, but the equipment won’t be. Before you make any purchases, you will need to find out whether or not you will be paid for them.

Does the Physical Therapist You See Need a Referral from a Doctor?

Before they will pay for any physical therapy appointments, several insurance companies require that you first get a recommendation from your primary care physician. Some people do not agree. 

Find out as much as you can before beginning any kind of treatment. In the event that you do require a reference, it is typically rather easy to request one from your primary care physician. It is an additional step, but doing so could end up saving you a significant amount of money.

How to Bring Down the Price of Physical Therapy

There is a possibility that your health insurance will not pay for physical therapy or that there will be a cap on the amount that it will pay for. Even if your insurer pays for a portion of the cost, you may still be responsible for paying significant out-of-pocket expenses. 

In the event that this occurs, you have the option of investigating whether or not you are able to use funds from your HSA or FSA to pay for your medical expenses. With one of these accounts, you can set aside money before taxes to pay for medical expenses as well as other expenses. 

This indicates that you are still responsible for making payments for the service, but the Internal Revenue Service will not ask you to pay taxes on the revenue that is used to make those payments.

 HSA benefits can be used to pay for a variety of medical expenses, including rehabilitation services such as physical therapy (PT). However, in order for physical therapy to count toward your treatment plan, a physician must first write you a prescription for it.

 Before beginning therapy at a facility, the American Physical Therapy Association (APTA) suggests that patients inquire about and request to examine the center’s financial policies. This will assist you in determining what your costs will be and how you will be able to pay for them in the future. 

There are additional ways to minimize the expense of physical therapy that you can take advantage of if you do not have an HSA or an FSA. If you are going to require more than one session of physical therapy, there are some therapists who may offer you a discount on their services. 

You can also obtain information about medical financing options or reductions by contacting the office of your doctor or the hospital where they work.

Key Takeaways

Before beginning physical therapy, you should verify with your insurance provider to see what kind of coverage you already have.

In order for your insurer to pay for physical therapy, they may require a reference from your primary care physician.

Make it a point to inquire about any coverage restrictions, such as the out-of-pocket maximums, deductibles, and the number of sessions that are covered.

If your insurer does not cover physical therapy, you may be able to pay for it using money from your health savings account (HSA) or flexible spending account (FSA), or you may be able to arrange financing through the facility where your physical therapist works.

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