Does Insurance Cover Physical Therapy?

Fran
Dani Milton
June 3, 2020

Many Americans rely on physical therapy (PT) to improve their mobility following an injury, surgery or long-term illness. This rehabilitative treatment can also reduce chronic inflammation and pain that patients may suffer. Although PT can be beneficial, it is sometimes costly without comprehensive insurance coverage. In today's article, you'll learn about how insurance coverage can pay for your physical therapy treatment.

What Is Physical Therapy?

The purpose of physical therapy (PT) is to help make daily activities and other tasks easier. Some people have difficulty moving around when they suffer from limitations due to chronic diseases, surgeries or injuries following an accident. Physical therapy helps you move, function and live a more productive life.

Physical therapists use rehabilitative exercises to treat mobility and fitness problems. Over time, they improve a patient’s balance, strength, endurance and coordination. These therapies can increase range of motion, flexibility and joint mobility while decreasing pain. PT can treat the following health and physical issues:

  • Help you recover from a significant sports injury.
  • Prevent disability or loss of physical function.
  • Provide rehabilitation after a stroke, accident, sports injury, or surgical procedure.
  • Improve balance and coordination issues.
  • Manage chronic health issues like heart disease, arthritis, and diabetes.
  • Allow mothers to heal after labor.
  • Help patients to adapt to artificial limbs.
  • Teach people how to use devices like walkers or canes.

Additionally, PT, like other exercise therapies, can also improve patients’ mood. According to a recent study, exercise can supplement traditional treatments and help people become more engaged and focused. Individuals who undergo exercise therapy report fewer symptoms of anxiety and depression as well as lower levels of anger and stress.

How to Find a Physical Therapist

Physical therapy is most effective when a trained professional with the proper certifications manages the treatment. When you’re searching for a qualified therapist to oversee your care, ask the following questions:

Before scheduling sessions, contact your insurance company to find out if your plan pays for PT. Ask what documentation they'll need before you enroll.

Speak with your primary care doctor and find out if he or she can recommend a good physical therapist.

Ask your physician for a written referral. Some states require patients to get these recommendations before patients start therapy.

Some physical therapists are board-certified specialists in specific disciplines such as orthopedics, neurology and sports. They may also have experience in the following areas:

  • Treating neck and back pain
  • Wound care
  • Cardiac rehabilitation
  • Cancer-related issues
  • Gait training
  • Care for children and the elderly
  • Ultrasound treatment for strained muscles

You can directly contact the physical therapist to get information about their specializations and the conditions they treat. The American Physical Therapist Association (APTA) has a database of qualified professionals across the country. You can access it here.

What Should You Expect During the Physical Therapy Process?

During an initial consultation, your physical therapist will gather your patient history. They’ll conduct a routine exam to assess your muscle strength, endurance and flexibility. Your therapist will ask about your goals for PT, health issues and any persistent symptoms that you have.

After your appointment, they’ll create a tailored treatment care plan for you. Your PT will prescribe sets of exercises and daily activities that will safely increase your stamina and build your strength and endurance. These include stretching, core-building exercises, walking on treadmills and lifting weights.

Your therapist may assign some home exercises, so you can continue improving between sessions. Additionally, this professional may work with your primary care doctor who can provide a long-term diagnosis and prescribe medications to improve your health. PTs use an hourly billing system, and their appointments usually last 30 to 120 minutes.

Will My Health Insurance Cover Physical Therapy?

Most major health insurers will cover physical therapy and other rehabilitation services. Under the Affordable Care Act, PT qualifies as an essential health benefit. These are ten categories of services that all healthcare insurance plans must cover under the ACA. It includes physicians’ services, inpatient and outpatient care at hospitals, prescription drug coverage, pregnancy and childbirth and most mental health services.

The government also deems rehabilitation services as medically necessary. According to HealthCare.gov, these are health care services or supplies needed to diagnose or treat an illness, injury, condition or disease that meet accepted medical standards. Most insurance companies pay 50 to 75 percent of the costs when PT is medically necessary. Services as medically necessary when they are needed to:

  • Improve your current medical condition.
  • Maintain your current state of health.
  • Prevent the deterioration of your physical condition or body.

The government doesn’t require non-marketplace plans, such as short-term health insurance, to cover the ten essential benefits, including PT. If you have one of these plans, you may have to pay for these costs out-of-pocket or rely on your Health Savings Account or Flexible Spending Account if you have one. Some insurers ask their customers to obtain a care plan and a referral from a doctor before starting PT sessions.

How Much Does Physical Therapy Cost?

PT patients generally attend several sessions a week for months at a time. Many patients must pay a copay for every visit. These fees remain the same throughout the course of physical therapy service. This payment schedule differs from other specialist appointments when patients spend hefty copays for an initial visit, but lower rates for subsequent ones. Your PT costs will depend on several factors. These include: Your current insurance plan

  • The PT procedures you need
  • How much your physical therapist charges for sessions
  • Your state or place of residence
  • The rehabilitation center where you’re receiving therapy
  • Whether you’re receiving inpatient or outpatient care

On managed care plans, cost-sharing may increase the costs of your physical therapy. If you have coinsurance, you’ll have to pay your deductible and a percentage of your physical therapy costs unless your insurer covers these services.

An initial evaluation may cost $150 - $225 or more. Your copays will differ depending on the type of treatment. Some can also run as high as $75 per session. If you need multiple therapy sessions, your costs can skyrocket. Some physical therapists may offer discounts for long-term treatment care.

Average Physical Therapy Sessions Cost Per Session

Here are the average PT per session in the U.S.:

With Insurance: $20 - $55 copay, or 10 – 50% coinsurance (after you pay the deductible. Average deductibles are $250 - $1,250).

Without Insurance: $75 - $150.

The average out-of-pocket costs for most physical therapy last year was $1,488. Some insurance companies ask for their customers to pay high deductibles before they can receive PT. If you’re in this situation, consider switching insurance companies. SmartFinancial can help you find a health insurance plan with better coverage and affordable deductibles in your area. You can reduce your PT 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. Some studies show these providers can save you up to 50 percent on your PT care.

How to Reduce Your Out-of-Pocket Physical Therapy Costs

You may have insurance coverage that doesn’t pay for all of your costs related to physical therapy or that has coverage limits. Some managed care plans have costs you’re responsible to pay, such as copays or coinsurance fees. If you have a Health Savings Account (HSA) or Flexible Savings Account (FSA), you can use these plans to pay for some medical expenses. According to the IRS, rehabilitation services are qualified medical expenses under HSA benefit plans; however, a physician must prescribe this treatment as part of your recovery plan. You should check the center’s financial policy before starting treatment at a physical therapy center.

Medicare and Physical Therapy

Many people seeking physical therapy are on Medicare. This federal health insurance program helps people age 65 years or older and younger people that have certain disabilities. It is also open to people with End-Stage Renal Disease (ESRD), a kidney failure condition that requires dialysis treatment or a transplant. Standard Medicare coverage runs between $26 and $30 for each weighted procedure and an average of $100 per PT session. Original Medicare (Parts A and B) will only cover a total of $2,050 for PT. If you need services beyond this, you’ll need proof from your physician. You may consider switching to Medicare Advantage, which offers greater coverage.

Medicare Part A

This part of Medicare is known as hospital insurance. Medicare Part A will cover the treatment that you receive during your inpatient stays at a rehabilitation center or a skilled nursing facility. It can also reimburse some home health care when your doctor deems it medically necessary to improve your recovery after a hospitalization.

Medicare Part B

This policy is medical insurance that covers essential outpatient services, like medically necessary physical therapy for patients. Medicare Part B also includes the diagnosis and treatment of chronic diseases and conditions that may require therapy. This policy also covers some preventative care. You can receive these services at the following locations:

  • Doctor’s offices
  • Private physical therapist practices
  • Skilled nursing facilities
  • Outpatient departments at rehabilitation centers or hospitals
  • At home, from a Medicare-approved physical therapist

Medicare Part C

Medicare Advantage Plans fall under Part C. Private companies provide this insurance to consumers. They include coverage offered in Original Medicare (Parts A & B) and other services, including dental, vision, and Part D Prescription coverage. Some plans also cover PT they deem as medically necessary. If you have a Part C plan, ask your insurance provider how they cover therapeutic services. If yours don’t offer enough, you can use SmartFinancial to search for a Medicare Advantage plan that covers physical therapy.

Medicare Part D

This insurance provides prescription drug coverage. It doesn’t cover physical therapy treatments, but it will pay for medications that are part of your recovery plan.

Medigap

Medicare supplemental insurance plan are known as Medigap programs. These plans won’t cover PT, but will pay for any associated out-of-pocket costs. Private insurance companies sell these policies to cover costs parts A and B don’t. They include:

  • Copays
  • Coinsurance
  • Deductibles
  • Medical Expenses outside the U.S.

11 Questions to Ask Your Insurer before Starting PT

Before starting your PT regimen, speak with an insurance representative or the therapy treatment center to find what your insurance will cover. Here are a few questions you can ask about your coverage.

1. Does my insurance cover occupational therapy and physical therapy? Some providers may not cover these services in full, although rehabilitation services are listed as one of the ten essential services under the Affordable Care Act. Contact your insurer to see what they cover.

2. Contact your insurance company to find out if your provider is in-network or out-of-network. You can check your insurer directly or use their online directory to learn this information. If you use an out-of-network provider, you’ll generally have to pay the entire cost for the services. You’ll even need to submit the bill to the insurance company for reimbursement yourself. Make sure that any provider you select is an in-network one, to have your PT covered.

3. Do I need a pre-authorization or a referral from my primary care doctor before starting PT? Some plans require a doctor’s referral before you schedule PT. Make sure that your physician completes the paperwork to authorize your physical therapy. You should receive an Explanation of Benefits (EOB) notifying you about your upcoming treatments.

4. Is there a deductible? Your insurer may cover the costs of you PT only after you pay your deductible. Contact your insurer to find out how much this fee is.

5. How many PT and occupational therapy visits are allowed? Some insurers only allow a specific number for PT. Ask how many sessions you’re allowed under your insurance plan.

6. Does my plan pay for PT or occupational therapy (OT) in an inpatient or outpatient setting? Some plans reimburse your expenses differently depending on the facility you use. Contact the PT center to find out if they offer inpatient or outpatient care.

7. If I need several therapies (OT, Speech, and PT) will I receive the same number of visits for each one?

8. Does my current plan have any limits or exclusions for PT? Your plan may not cover therapeutic services if you (or a covered family member) has a pre-existing condition. For example, some providers require a new referral for PT every 12 months. Others will only pay for the first evaluation with the physical therapist, but not ongoing care until they review your doctor’s care plan and approve the visits.

9. How much will I need to pay out-of-pocket for my physical therapy? These costs may include copays (that are due on the day of your appointment), coinsurance, and deductibles.

10. Is there a cap on the number of my PT visits? Some coverage prohibits services you can get within the first 90 days of your plan. This issue can stop you from accessing essential treatment.

11. Ask Your insurer if they pay for a Maximum Dollar Amount for PT - Your plan may have lifetime maximum or per-condition limits on the policy. Lifetime maximum insurance benefit is the highest dollar amount that your insurer will pay out during the lifetime for your non-essential healthcare services.

Do you need an affordable health insurance policy that will cover your PT? SmartFinancial can help you find a great health insurance policy that can help. Fill out our simple application, and you’ll receive insurance quotes from multiple insurance companies in your area within a few minutes. You can also get assistance from one of our insurance concierges on the phone at 855--214-2292. SmartFinancial will provide you with options to buy one of our policies online or over the phone. Our transparent insurance technology does all the work for you.

Get a Free Health Insurance Quote Online Now.

Related Articles

Health Insurance 16 Must-Read Books on Mental Illness

The federal agency also says that 50 percent of the U.S. population will receive a mental illness diagnosis at some point during their lives. To help you along your journey, here are 16 books on mental illness that can help you heal.

Health Insurance Is There Health Insurance for Healthy People?

If you are healthy and looking for a couple of preventative care checkups a year, you may want to consider a high-deductible health plan or a bronze tier plan. You’ll like the cost.

Looking for Health Insurance?

Compare rates from dozens of companies in less than 3 minutes.