Is Physical Therapy Covered by Insurance?

Physical therapy is a key part of many health programs. There are many times when a doctor may decide that physical therapy, or PT, is something you need. You might have an injury or have recently gotten surgery. You may also have an existing condition that can be managed with PT.

The cost of physical therapy, though, can add up. You will often need more than one session, which can happen over many weeks or months. You'll need to pay for each of these treatments. For example, the cost of a single session of physical therapy after rotator cuff surgery can range between $50 and $350. If your health plan covers the treatment, you may only need to pay the copay and coinsurance. Still, these can add up. Many patients need up to 36 PT appointments to restore proper movement following rotator cuff surgery. It can be hard to cover these costs out of pocket.

Many health insurance plans cover PT. To be covered, though, the sessions need to count as an "essential benefit." This could be:

• Preventative and wellness services
• Managing a chronic condition
• Rehabilitative and habilitative services

If the therapy your doctor prescribes does not count as an essential benefit, it may not be covered. Before you go to PT, you should check whether sessions will be covered by your health plan. You'll also want to know how much of the cost your plan will cover since it might only pay for part of it. Ask these key questions to find out.

Is Physical Therapy Covered By Your Insurance Plan?

Affordable Care Act (ACA)-compliant and state-marketplace health insurance offer ten "essential benefits." Under the law, these plans must cover anything that counts as one of these benefits. This doesn't mean PT is only covered if you buy insurance on the marketplace. If you have a federally qualified HMO plan through work, your PT should also be covered.

In most cases, your insurance company will tell you one of three things:

• PT isn't covered: You'll pay the rate your insurer set with the physical therapist.
• PT is covered: Your insurer pays a percentage of the bill, known as coinsurance.
• PT is covered: You pay a flat fee for your visit, known as a copay.

Also, some physical therapy could be covered if it is preventative. This means it makes an injury or illness less likely to occur. For example, your plan may cover PT that helps prevent seniors who live in a community setting from having falls.

What to Ask Your Health Insurance About PT Coverage

Before you get treatment, always contact your health insurance provider. You'll need to confirm with them that your physical therapy will be covered. You should ask additional questions to avoid having a claim denied or being stuck with surprise bills, too.

Is There a Maximum Dollar Amount Your Insurer Will Pay for Your PT?

Ask about the lifetime maximum, annual, or "per-condition" limits. For example, you may need physical therapy due to a running injury in March. Then, in July, you may hurt your back and need PT again.

What will happen if you need PT more than once in a year? Will that change if it's for the same problem or two different ones? Will one limit apply, or is there a limit for each condition?

Do You Need to Use an In-Network Physical Therapist?

Not every physical therapist will be the right fit for every patient. Some specialize in certain injuries or treatments. You may find that you can only get the treatment you need with someone who is out of your network. Ask about costs or limits on coverage if you go out of network. Compare this to the cost for in-network care.

Is There a Deductible?

Your insurer may cover all or some of your PT costs right away. They may also step in only after you meet your deductible. Knowing which one will happen ahead of time can help you plan your budget.

Is There an Out-of-Pocket Maximum?

If you require a lot of PT, an out-of-pocket maximum will help you save money. This max is the most you can be made to pay per year. Should you reach your out-of-pocket limit, any other PT could be fully covered. This often is subject to the terms of the rest of your health plan.

Is There a Limit on the Number of Visits or Time in Which You Can Get PT?

Some plans may limit the services you can get for up to the first 90 days you have the plan. This could prevent you from getting the treatment you need. If this is the case, talk to your doctor. They may be able to contact your insurer and arrange a waiver for treatment that can't wait.

Does Your Plan Include Coverage for Equipment or Devices?

In some cases, your physical therapist may say you need to do at-home therapy or exercises to help with your recovery. Some of these may be simple to do. Others may need special equipment.

Some plans may cover your visits but not the cost of equipment. You'll need to know before you buy anything whether you will be reimbursed or not.

Does Your PT Require a Recommendation From a Doctor?

Some insurers require you to have a referral from your doctor before they will cover any PT sessions. Others may not. Be sure to find out before you start any treatment. If you do need a referral, it is often simple to ask your primary care doctor for one. It's an extra step, but one that could save you a lot of money.

How to Reduce Physical Therapy Costs

You may find that your health insurance does not cover physical therapy or that there are limits on your coverage. You may also be stuck with high out-of-pocket costs even if your insurer covers some of the price tag.

If that happens, you can look into whether you can use your HSA or FSA to pay your medical costs. These accounts allow you to set aside money for medical (and other) costs pre-tax. This means you still have to pay for the service, but the IRS does not require you to pay tax on the income you use to pay the bill.

Rehabilitation services, such as PT, are one of the medical expenses included in HSA benefits. But a doctor has to prescribe PT as part of your care plan for it to count.

If you don't have an HSA or an FSA, there are other ways to lower the cost of PT. If you will need more than one session, you may be able to get a discount with certain physical therapists. You can also get information from your doctor's office or the hospital about medical financing options or discounts.