If you have ever had this question, you are not alone: medical insurance is a confusing topic. With open enrollment period currently in effect, understanding the various aspects of insurance coverage is not only relevant, but crucial.
This article provides a general overview of some of the common questions our patients have about their health care plans. We hope that it is a useful resource for you to help determine how much your physical therapy sessions will cost.
Don’t forget to check out our other patient educational pieces, “How much Will Physical Therapy Cost with Unitedhealthcare“ and “How Much Will Physical Therapy Cost with Aetna?” for more specific information about these particular providers.
If you have any questions, please do not hesitate to reach out to the front desk staff at COR via email [email protected] or phone 408-905-6483. We work hard everyday to ensure that there are no surprises when it comes to your payment for services provided by our staff members.
With that being said, let’s dive in: its definition time.
Health Insurance Key Words/Phrases
Consider this like a fee to belong to a club. This is the dollar amount that you pay every month based on the plan you select. Similar to a fancy gym membership, it allows you access to the services that the club has available; but instead of weight machines and yoga classes it is access to the service providers (physicians, physical therapists, etc) that help manage your healthcare. This monthly payment does not apply to your deductible.
This is the dollar amount that you have to pay before insurance will cover any of the cost of your medical treatment. Say you sign up for a health insurance plan with a $500 dollar deductible. At the beginning of the year you schedule an appointment with your physician: this costs $400. Then you schedule a physical therapy session and that costs $100. Now your deductible is met! While you will have to pay $500 up front for your two previous appointments, you will now be covered by your insurance (at a certain percentage) for the remaining expenses throughout the year. After a deductible is met, generally a co-pay, co-insurance or a combination of both will begin to apply to future appointments.
This is a fixed payment amount, paid at the time of service. For example, say your co-pay for physical therapy is $25. Every time that you come to your physical therapy session (after your deductible is met), you will be charged $25 from the front desk personnel at the office. This amount contributes to the out of pocket maximum.
As mentioned previously, after you have met your deductible (Ex. $500) insurance will help you pay for all future covered treatments at an agreed upon percentage. Say your coinsurance is 20% of treatment costs. This means that after the deductible is met, if you have an appointment that costs $100, you will pay $20 and the insurance will pay $80. The amount that you pay contributes to the out of pocket maximum.
Out of pocket maximum
The coinsurance or copay payment will apply until you meet your “out of pocket max.” This is a cut off point after which, your insurance company will cover all additional, medically necessary expenses at 100%.
Say your out of pocket max is $5000. Through a combination of appointments with your physician and physical therapy, you reach this in October. Now all future costs for medically necessary care will be covered. So, if you get in an accident, at the end of the year, that requires $30,000 of medical bills, this will all be covered by insurance at 100%.
Your Insurance Benefits
Before you start physical therapy at COR, your insurance benefits will be verified by the front desk staff. This will occur either when you call to schedule your first appointment or at the time of your first appointment. It is our goal to get this information as early as possible so that we can let you know how much your physical therapy appointments will cost. We do this by looking carefully at your deductible, total yearly cost, out of pocket max and copay/coinsurance. While we realize that this process can be confusing, we hope to simplify it for you as much as possible. As always, let us know if you have questions at any time throughout your treatment plan.
As is the case with most things in life, exceptions do apply and the best way to ensure that you do not receive any surprise bills is to talk directly with your insurance provider. For tips and a step by step guide on how to do this, please refer to our other articles: “How much Will Physical Therapy Cost with Unitedhealthcare“ and “How Much Will Physical Therapy Cost with Aetna?”
Types of Plans
Another important aspect of understanding your health care plan is determining your coverage with “in-network” versus “out of network” providers.
The insurance plan that you choose will generally fall into 1 of 3 categories: HMO, PPO, EPO. Depending on your plan, you will have different coverage for in-network providers versus out of network providers. You can read more about these categories below:
With this type of plan you must stay in-network in order for your insurance provider to cover the cost of your care at the agreed upon rate. If you decide to go out-of-network for any health care appointments, you will pay out of pocket for the costs.
The major exception to this is with emergency care, in which case insurance companies are required to pay as if the provider was in-network.
“In-network” refers to a list of providers, medical systems etc. that your insurance provider has selected to have a contract with. In order to be listed on an insurance provider’s in-network list, providers must apply. For example, in order for COR to be considered in-network with Unitedhealthcare, we had to go through an application process. Completing the process is beneficial for all parties, as now our clinic is able to help patients in the area with United Healthcare achieve their physical therapy goals. In return a specific rate or fee for service is negotiated with Unitedhealthcare for the care we provide. For more information about negotiated rates please see the “Negotiated Rates” section in a similar article on our website, “How Much Will Physical Therapy Cost with Unitedhealthcare?”
As mentioned previously, with an HMO plan, services from out of network providers are not covered (unless, of course, they are emergency services). Here is a case scenario that we have seen fairly commonly in the patients that we treat.
Let’s say you are enrolled in a Kaiser HMO plan. You call our clinic to see if physical therapy services will be reimbursed by your health care coverage. You learn that since physical therapy is a non-emergency service, you would not receive reimbursement for the physical therapy care provided by COR and would therefore have to pay the pre-negotiated price, out of pocket for all of your treatments.
With a PPO plan, you are not required to stay “in-network” for medical services. These plans also do not require you to select a Primary Care Physician (PCP) or require you to have a referral to see a specialist.
The major difference between EPO plans and PPO plans is that with an EPO you must stay in network for medical services in order for your insurance to pay for treatment.
In Network at COR
How Much Will Physical Therapy Cost?
At this time of year, it is likely that your sessions will cost less than they would have at the beginning of the year due to the increased likelihood that you have met your deductible and out of pocket max.
Below is a case involving out lovely patient Mary. Let’s pretend the Mary is in need to 5 physical therapy sessions at some point during the year. Here are the details of her insurance coverage.
Mary’s Healthcare Plan
Provider: Aetna (In-Network)
Out of Pocket Max: $5000
Co-Pay (for Physical Therapy): $25
Negotiated Cost of Physical Therapy Session (In-Network): $68
In the chart below, the date indicated in the first column is the date she calls COR to ask how much her 5 sessions of physical therapy will cost. The dollar amount in the second column indicates the total amount she has paid this year for medical treatment at the time she calls. Her total health spending for medical treatment is a combination of physician visits, procedures, imaging, etc.
|Date||Total Health Spending this Year||Number of PT Sessions||Price Mary Pays for Each PT Session||Why?|
|January 1||$0||5||$68||Mary will pay the full, negotiated, in-network price because she has not met her deductible yet.|
|March 1||$500||5||$25||Since she has met her deductible, Mary no longer pays the full price for treatment. She pays the co-pay at each session.|
|December 1||$5000||5||$0||Since she has met her out of pocket max, Mary now pays $0 for her physical therapy sessions for medically necessary care.|
As the chart demonstrates, if Mary requires a total of 5 physical therapy sessions, she may pay a different cost per session depending on how much money she has paid in total this year for the medical services she has received.
At COR, it is our goal to improve healthcare transparency. If you have questions about how much your physical therapy treatment will cost, please reach out to us via phone at 408-905-6483 or send us an email to [email protected]: we are happy to help. However, as mentioned previously, exceptions do apply and the best way to verify insurance benefits is talk with your insurance provider directly.
At COR, we also offer a Free Physical Therapy Consultation, to help improve health transparency, answer questions, and set-up the perfect plan of care to your individualized needs.
If you are having any pain pre- or post-partum and you want to Solve Your Shoulder Impingement? Schedule a Free Success Session today:
In 4th grade, when asked what she wanted to be when she grew up Dr. Erin Cameron, DPT replied “physical therapist,” a rather unconventional response for a child that age. She was a young swimmer with shoulder pain, desperate to return the to sport that she loved so dearly. The dedication of her physical therapist allowed her to pursue her passion and eventually go on to compete at the collegiate level.
While swimming at the University of Michigan she studied to obtain a Bachelor of Science in Movement Science from the School of Kinesiology. During her collegiate swimming career, she earned the following accolades: two-time CSCAA Honorable Mention Scholar All-American, three-time Big Ten Distinguished Scholar, team captain and the Michigan Leadership Academy Leader of Distinction award.
Erin has dedicated much of her life to the sport of swimming. In addition to competing in the sport for 15 years, she has coached at various elite swim camps and clinics growing her expertise in stroke technique and video critique. She has also served as a volunteer staff member for Division I, II and III swim programs aiding in both coaching and developing exercise programs/educational sessions for upper extremity injury prevention.
Erin received her Doctorate in Physical Therapy from Northwestern University’s Feinberg School of Medicine. During her time in physical therapy school, she developed a special interest in treating patients with a broad range of orthopedic injuries and promoting general health and wellness.