Physical therapy is a key component in many rehabilitation and recovery programs. In some cases, your doctor may consider physical therapy necessary to help you recover from an injury, post-op effects or existing conditions.
The cost of physical therapy can easily add up since it is not something that works in one session but usually requires several treatments.
For example, a study from 2015 showed that patients could pay $2,807 to $3,376 for up to 36 PT appointments following rotator cuff surgery.
If you are wondering if physical therapy is covered by health insurance, the good news is that many health insurance policies cover physical therapy (PT). However, the appointments need to fit the criteria of an “essential benefit.” If the recommended therapy is not an essential benefit, it may not be covered.
Here’s how to know if your health insurance policy covers your physical therapy appointments and some key questions to ask before you go.
Is Physical Therapy Covered By Your Insurance Plan?
The law requires physical therapy and other rehabilitation services to be covered by Affordable Care Act (ACA)-compliant and state-marketplace health insurance under “essential benefits.”
If you have a federally-qualified HMO plan through your employer, your physical therapy will be covered, according to the American Physical Therapy Association (APTA).
In most cases, your insurance company will tell you one of three things:
- The PT isn’t covered and you’ll pay the rate your insurer negotiated with the physical therapist.
- The PT is covered and your insurance company pays a percentage of the bill (“coinsurance”).
- The PT is covered and you pay a flat fee for your visit (“co-pay”).
Also, some physical therapy could be covered if it is preventative. For example, your plan may cover physical therapy that helps prevent seniors living in community settings from having falls.
Some short-term health insurance plans and other non-ACA-compliant insurance may not cover physical therapy.
Seven Questions to Ask Your Health Insurance About Physical Therapy Coverage
Before you get treatment, always contact your health insurance provider and confirm with them that your physical therapy will be covered. You’ll need to ask additional questions to avoid having a claim denied or being stuck with unexpected medical bills, too.
Health insurance policies provide coverage for physical therapy by a licensed physical therapist if it is habilitative or rehabilitative and medically necessary. Some insurance companies, therefore, may require a doctor’s recommendation. What’s required may vary from state to state.
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 require physical therapy to recover from a running injury in March. Then, in July, you may require physical therapy for a back problem.
How will your health insurance handle the limitations in this circumstance? Will one limit apply, or is there a limit for each condition?
Are you required to use an “in-network” physical therapist?
Ask about restrictions or limits on coverage if you go out of your network and compare this to the coverage for “in-network” care.
Is there a deductible?
Your insurer may cover all or some of your PT costs, but only after you meet your deductible.
Is there an out-of-pocket maximum?
If you require a lot of physical therapy, an out-of-pocket maximum will help you save money. Should you reach your out-of-pocket limit, your remaining therapy could be fully covered (subject to the terms of the rest of the policy coverage).
Is there a limit on the number of visits or time period in which you can get physical therapy?
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 accessing the necessary treatments within the plan guidelines.
Does your plan include coverage for equipment or devices that may be needed to assist with physical therapy or rehabilitation?
Your plan may cover your visits but not the cost of buying equipment your physical therapist says is necessary for at-home therapy and exercises.
Does your physical therapy treatment require a recommendation from a doctor before your health insurance will cover you?
Some insurers require doctor’s recommendations (“referral”), and others may not. Be sure to find out before you start any treatment.
How to Reduce Physical Therapy Costs
If your health insurance does not cover physical therapy, there are limits on your coverage or if you have high out-of-pocket costs, look into whether you can use your HSA or FSA to pay your medical costs.
For example, the IRS lists “rehabilitation services” as a medical expense included in your HSA benefits. However, a doctor has to prescribe PT as part of your care plan.
Also, the APTA recommends that before you start treatment at a physical therapy center that you ask to see their financial policy.
You may be able to negotiate a discount with certain physical therapists for multiple sessions or get information from your doctor's office or the hospital about medical financing options or discounts.
- Always contact your insurance company first to check what coverage you have (or don’t have). Make sure you don’t need a doctor's referral before your physical therapy coverage kicks in.
- In the event your current coverage is not enough for your needs, consider exploring other health insurance coverage options
- If you have a spouse or domestic partner who has access to a health insurance plan through their employer and they can add you to their coverage, you could benefit from coverage on both their plan and yours using coordination of benefits.
- Finally, remember that asking questions to get the best physical therapy coverage for yourself and your family is worth the time. It can save money on your physical therapy costs and help you live a more comfortable and healthy lifestyle.