Woman needing physical therapy

Understanding Insurance Coverage for Physical Therapy

Trying to understand how physical therapy is covered by your insurance can be confusing at best and infuriating at worst. In this article you’ll learn insurance terms and the most common ways physical therapy is covered.

Physical Therapists are Specialists

Why isn’t the copay for physical therapy the same as seeing my doctor? A Physical Therapist is considered a specialist by insurance companies in most states, including Idaho.  Most insurance plans require patients to pay more to see a specialist. For example, your doctor visit may be a $25 co-pay and a specialist may be a $50 co-pay. Or, your insurance may require you to meet your deductible when seeing a specialist.

What Type of Insurance Coverage is Most Common for Physical Therapy?

Here are the three most common types of physical therapy coverage we see:

  1. Deductible, then co-insurance
  2. Co-pay only
  3. Deductible, then co-pay

1. Deductible, then co-insurance

What is a deductible?  The deductible is the amount you pay out of pocket before your insurance will cover any portion of your physical therapy visits. Deductibles reset at the beginning of your benefit period.

After your deductible is met, your insurance begins to pay some of the costs. But they require you to pay a portion, called co-insurance.

What is co-insurance? The percentage of the visit you’re responsible for after meeting your deductible.  For example, your insurance pays 80%, and you pay 20%. Your insurance plan determines the co-insurance percentage.

2. Co-pay only

What is a co-pay?  A co-pay is a flat fee you pay for each visit. Your insurance plan determines the co-pay amount.

3. Deductible, then co-pay

Some plans require you to meet your deductible before you pay a co-pay for each visit.

Other Coverage Terms

Out of Pocket Maximum:  The amount you pay out of pocket during your benefit period before your insurance will cover 100% of your medical care. This is usually a large amount (i.e. $10,000 or more).  This resets each benefit period.

Benefit period:  The 12 months that make up your benefit year, decided by your insurance plan.  Most commonly, insurance plans have a benefit period of January 1 to December 31. This includes participants in the Idaho Health Exchange, or those who purchase individual coverage. Check with your employer or insurance plan to learn what your benefit period is.

Physical therapy limits: Most insurance plans have a limit on the number of physical therapy visits they’ll cover in a benefit period.  For example, a common amount is 20 visits.  With some insurance companies, that’s a hard limit.  Other insurers will approve more visits if the provider makes a good case for medical necessity based on documentation.

Do I need a referral? Most states allow some form of direct access, meaning that you can go directly to a physical therapist without a referral from your doctor. Idaho allows full direct access.  Regardless, some insurance companies require a referral before they’ll cover your visits. That means you don’t need a referral unless your insurance carrier requires it.

Do I have physical therapy coverage?  There are very few insurance plans that do not cover physical therapy, although they do exist.

Check with your insurance company to learn the details of your plan. When you shop for a new insurance policy, consider how physical therapy will be covered.

Considerations When Shopping for Health Insurance

If your employer supplies your health insurance, you’ll have to choose from the provided options. If you’re in a position to choose, it’s important to note that the monthly bill you pay doesn’t tell the whole story. For example, a plan with a lower monthly premium typically comes with higher out of pocket costs (i.e. high deductible) when you use your benefits.

Weigh the benefits and risks. Do you want to pay less up front and have significant medical bills if something were to happen? Or, do you need the security of being covered no matter what happens? Obviously, it’s a complex decision to make depending on your life circumstances.

We hope you’ve learned something new about how your insurance plan might cover physical therapy. Interested in knowing how much physical therapy will cost? Click here to learn more.