Is Physical Therapy Covered By Insurance?

Jan 30, 2022

If you’re in need of medical care, the process can be overwhelming: you have to find a doctor, maybe through a referral, and make an appointment, all while worrying about your health. It can be even more complicated when you have to think about insurance and whether treatment will be covered or cost you a huge amount out of pocket. This can especially be a concern for something like physical therapy services that require multiple sessions. While every plan is different, the good news is that insurance often covers physical therapy. Below is what you need to know about getting this coverage and answers to common questions.

Common Insurance Rules

Any insurance compliant with the Affordable Care Act (ACA) and any state-marketplace insurance offers a standardized ten “essential benefits.” The law then dictates that these plans must always cover anything that counts as one of these benefits. However, even if your insurance is not bought through the marketplace, you can still get this coverage. A federally qualified HMO plan through an employer will usually also cover physical therapy.

There are three typical scenarios that you can encounter:

  1. Your insurance has no coverage for physical therapy, and you pay an out-of-pocket rate.
  2. Your insurance will pay part of the bill for physical therapy, known as coinsurance.
  3. Your insurance covers physical therapy, and you pay a copay.

Coverage may also depend on why you need the therapy. In most cases, insurance will need evidence of an injury or surgery that requires it, but some preventative care may be available. The insurance company’s goal is to spend less on your care, so preventing future problems may be a worthy investment for them.

What to Ask Your Insurer

The best way to understand what is and isn’t covered is to speak with your insurance provider. They can confirm coverage upfront so that you can avoid a denied claim or surprise bills.

Is There a Maximum Dollar Amount of Coverage?

Ask about maximums- these can be on a per-condition, annual, or lifetime basis. Understanding what happens if you need PT more than once in a year, for multiple conditions, or later in life will be important in determining when to use this coverage.

There may be other limits, such as fewer services available in your first 90 days on the plan. Any limitations like this should be discussed with your insurance provider.

Do Providers Need to Be In-Network?

Insurance companies have made arrangements with certain providers to reimburse them set fees. Often, if you use a provider who is not in this network, you may have to pay more on top of insurance coverage. If you have a physical therapist you want to see, ask if they are in-network and what options are available if they are not.

Is There a Deductible or Out-of-Pocket Maximum?

Many people get these two items confused, so it is good to know what each is for your plan. A deductible represents the amount you need to pay before insurance kicks in each year. You may have higher bills upfront, and when you hit your deductible, you will pay very little. A higher deductible means it will be harder to reach that point.

An out-of-pocket maximum is usually larger and represents the most you will have to pay out of your own pocket- this includes your deductible, copays and coinsurance, and any other costs. If you hit this number, you will not have to pay anything else for the year.

What About Equipment and Devices?

In some cases, physical therapy may involve an at-home component, such as exercises or assistive devices. Some plans may cover visits but not extend to these devices, while others offer this coverage. Before you buy anything, it will be important to know if you will be reimbursed or not.

Do I Need a Referral?

Insurance will sometimes require your primary care physician to refer you to specialists like physical therapists before they will cover it. Before you start treatment, make sure you know if this is necessary and get a referral if so to avoid denied claims.

Reducing Physical Therapy Costs

Whether your insurance covers none of your physical therapy or the majority of it, there may be ways to make the care more affordable. For example, if you have an HSA or FSA account, these pre-tax funds you’ve set aside can be used to pay for sessions, equipment, and any related costs. You will usually need a prescription for the services in order to use these options, but this is usually easy to get written out so you can pay with your card.

Doctors may also be willing to work with you if you have no or little insurance. A cash rate will often be lower than the rate negotiated with insurers, or they may offer payment plans and financing. You can also often request a discount if you commit to a certain number of sessions. In case you are confused between physiotherapy vs physical therapy here is complete a guide for you.

The Right Care

While physical therapy may require multiple sessions, the goal is to address the root cause of issues and build up strength and skills that prevent future injuries. By investing in physical therapy at the start of symptoms or after an injury, you may be able to avoid more serious problems in the future that could be even more costly. At AICA Jonesboro, we understand that treatment can be expensive and will work with each patient to achieve the maximum possible results in the shortest time possible.

If you are unsure about your coverage and want to understand the exact costs, contact AICA Jonesboro today to speak with our staff. They will be happy to take your insurance information and share the best way to achieve coverage for you and your needs. We work with most major insurance providers to bring care to as many people as possible and will do everything we can to ensure you get the care you need affordably.


Contact Us

  • This field is for validation purposes and should be left unchanged.