Will My Health Insurance Policy Cover Physical Therapy?
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If you suffer from chronic pain and need relief, are recovering from surgery or need to strengthen weakened joints, you need physical therapy to heal and recover. In some cases, physical therapy can even prevent health issues from cropping up. Most major health insurance plans, including private insurance, Medicare and workers' comp cover physical therapy (PT) when it is medically necessary. Physical therapy is an essential health benefit and is a key part of many health care programs.
When Does Physical Therapy Cover Insurance?
Under the Affordable Care Act, state-marketplace and ACA-compliant health care insurance plans must offer ten categories of essential services, including
- Emergency services
- Ambulatory services
- Pregnancy and maternity services
- Pediatric services
- Rehabilitative services and devices
- Mental health services
- Prescription drugs
- Preventive services
- Laboratory services
For most plans, physical therapy falls under "rehabilitative services and devices" or "preventive services" since it is used to diagnose or treat an injury, disease or condition.
The government doesn't require non-marketplace plans, such as short-term health insurance, to cover the ten essential benefits. If you have one of these short-term plans, you may have to pay for these costs out-of-pocket or rely on your Health Savings Account or Flexible Spending Account. Some insurers ask their customers for a doctor referral before covering PT sessions. If you have insurance through your employer, physical therapy is probably a benefit.
How Much Does Physical Therapy Cost With Insurance?
Your insurer can tell you if your policy covers physical therapy and what your out-of-pocket costs might be; most insurers cover 50 to 75% of the costs for medically approved physical therapy. Overall, policyholders may expect to pay between $10 to $75 copay for each session of physical therapy. Most insurers will cover at least 50% of the costs, but some may require you to pay your yearly deductible first, which can be anywhere from $250 to $1,250. While the cost of physical therapy is lower when you are covered under a health plan, it's usually not free. You may need to pay your health insurance deductible first before you can see insurance coverage: your copayments and insurance payments don't count towards the deductible.
The average out-of-pocket cost for most physical therapy sessions is $150 without insurance. You can reduce your physical therapy costs by using an in-network provider on your insurance plan. These therapists already have a contractual agreement with your insurer to charge specific prices in exchange for referrals.
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How Do Different Health Insurance Plans Cover Physical Therapy?
Several different factors impact whether or not your insurer will cover physical therapy, one being the type of health plan you have:
Individual health insurance plans
Often cover physical therapy, but not 100%
Most likely to cover physical therapy of all plans
Medicare Part B covers many forms of physical therapy (with some limitations)
Since the federal government sees physical therapy as an optional benefit, states can choose to cover it, and very few do.
Non-marketplace plans are not required to cover the ten essential benefits, which include physical therapy.
Does Job-Based Health Insurance Cover Physical Therapy?
If you get health insurance from an employer, it will likely cover physical therapy visits and costs. Many large employers include coverage for physical therapy to attract and retain talent and to compete with other organizations and companies. In the past, you would not have been so lucky with smaller employers until the Affordable Care Act was introduced in 2010. Under Obamacare, essential benefits were established, including physical therapy.
Today, all health insurance plans sold through the federal marketplace must cover these ten service categories, which means that even small group plans will include them, as well. But that doesn't mean that all small group plans completely cover physical therapy, especially if they are grandfathered in. Furthermore, small group health plans are allowed to set limits on how often or how many times their members can receive treatment.
Larger employers may have fewer restrictions or caps on physical therapy care, but policies vary from employer to employer.
What To Ask Your Health Insurance Carrier About PT Coverage
You should always contact your health insurance provider before starting any treatment, including physical therapy. It's important that you confirm that they will cover your sessions. There are a few questions you should go over to avoid getting stuck with a surprise bill or having your claim denied.
Do I Need a Recommendation From a Doctor?
Some insurers require that you get a referral from your doctor before they will cover physical therapy sessions, while others won't. You should ask your insurer before you start treatment. If you do need a referral, it is often as simple as asking your primary care doctor for one.
Is There a Maximum Dollar Amount for Physical Therapy?
Insurance companies often have lifetime maximum, annual, or per-condition limits. If, for example, you need physical therapy for an injury dating back to January, but then you hurt yourself again in May, that could impact your insurance coverage.
Do I Need to Remain In-Network?
The physical therapist you want or need may not be in your network, but your insurance may require that you stay within their network to provide maximum coverage. This could pose a problem if the physical therapists in their network don't specialize in your injuries. It's important to ask about costs or limits on coverage if you are considering going out of network for special needs.
Is There a Deductible?
Some insurers may cover your physical therapists in full, while others will only start paying after you've met your deductible. It's important to know which applies to your health plan so you can plan your budget.
Is There an Out-of-Pocket Maximum?
If you have an injury or illness that requires many physical therapy sessions, an out-of-pocket maximum can save you money. Once you reach your max limit, physical therapy sessions should be fully covered.
Does My Plan Include Equipment Coverage?
Some healing and rehabilitative treatments require in-home therapy with specialized equipment. Some health plans will cover your visits but not special equipment, so it's good to find out if you will be reimbursed or not before you make an appointment.
Is There a Limit on the Number of Physical Therapy Sessions?
Some health plans place a limit on the number of physical therapy sessions you can have for the first 90 days of the plan, which could hinder you from getting the full treatment that you need. If your treatment can't wait, you may be able to talk with your insurer to arrange a waiver.
What To Do if Your Health Plan Doesn't Cover Physical Therapy
If your health plan doesn't cover physical therapy, you can still pay out-of-pocket for the treatment that you need. You can also pay out-of-pocket if your physical therapist is not in-network.
If the cost is prohibitive, contact your physical therapist and see if they can recommend a few ways to recover quickly — even if you can only see them for one or two sessions. A few ways to aid in your recovery include:
Ask for a home exercise program designed just for you
Follow your self-management plan: consistency is key
Educate yourself on how to improve your condition; your physical therapist should be able to answer any questions you have
Make active changes in your daily routine to aid in your recovery
Ask if your physical therapist will work with you on a payment plan
Consider CareCredit for healthcare financing
Utilize your Health Savings Account (HSA) or Flexible Savings Account (FSA)
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Speed Up Your Recovery With the Treatments You Need
Some insurance companies will cover PT while others require that you meet a high deductible before they start paying for physical therapy sessions. If you're not happy with your current health plan, consider switching insurance companies. SmartFinancial can help you find a health insurance plan with better coverage and affordable deductibles in your area. Start by entering your zip code below and filling out a short questionnaire within a few minutes.