Understanding Health Insurance Benefits

by Specialized Orthopedics August 01, 2022
Understanding Health Insurance

A day does not go by when our Patient Care Coordinator is not explaining health insurance benefits to someone who is confused by what his or her coverage is for Physical Therapy services.  Unfortunately for all of us, health insurance coverage and benefits have become exceedingly confusing and complex, including for Physical Therapy services.  We will try to help you focus on the following concepts to make it a little easier to understand.

Deductible:  This is the amount of money that you are expected to pay for various healthcare services rendered (including Physical Therapy) before your insurance company will begin to pay for these services in a particular year.  Deductibles range from $250 per year to $10,000 per year.  However, there are certain services that the deductible does not apply to (ex: yearly physicals, mammograms, etc.) and your insurance plan covers.

Co-Insurance:  This is the amount of money that you will be responsible for a health care service rendered such as Physical Therapy.  The Co-Insurance is typically listed on your policy as a percentage that the company will cover (ex. 80%/20%).  In the example here the insurance will pay 80% of the allowable charges and the patient will be responsible for the remaining 20%.  This type of plan is more common than people think as Medicare and many BCBS insurance plans pay for Physical Therapy services on an 80%/20% basis.

Co-Pay:  This is the amount of money that you will be responsible for Physical Therapy services regardless of the number of allowable charges.  This is a set fee and will not change even of the level of services does change.  Co-pays can range from $10 per visit to $65 per visit.  A great example of this is Emergency Room Visits.  Many Medicare replacement plans have a set co-pay as well as some United Healthcare plans, Tufts, and Neighborhood Health.

Visits Allowed:  This is the number of Physical Therapy visits your health insurance will allow in a year.  Plans range from 20 to 100 visits per year allowed.  There are also several plans where visits are “based on Medical Necessity”.  This means that you are allowed as many visits as what would be considered “medically necessary”.  In this case, it is based on the clinical judgement of the Physical Therapist as well as in agreement with the ordering physician or specialist.  There needs to be coordination and written communication (progress notes) between your PT and your physician to justify “medical necessity”.

At Specialized Orthopedic Physical Therapy, our Patient Care Coordinators will verify your benefits as well as explain what your individual plan benefits are upon commencing your treatment program.  This is accomplished by the Patient Care Coordinator looking up your benefits online with your insurance company or through direct phone contact.  These benefit summaries are provided as a courtesy to our patients and do not guarantee payment by the insurance company.  While we provide this information, it is always the consumer’s (patient’s) responsibility to know and understand their health benefits.

If you have any further questions, please contact our Patient Care Coordinator at our Warwick (401-384-6490) or North Kingstown (401-329-0050) office(s).

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