Insurance Basics

Health insurance can be confusing! While many of us have health insurance, we might not understand all the ins and outs of our individual plans. Understanding your physical therapy insurance benefits can make the process of getting care less intimidating and less stressful. A little time spent to learn the basics can take you from feeling in the dark to feeling empowered!


Let’s start with the basics!


Health Insurance: a contract that requires your health insurer to pay some or all of your healthcare costs in exchange for a premium.


Premium: the amount of money paid (typically each month) to have an active health insurance plan. 


Let’s define some other words we often see in health insurance plans:


Member: a person who is enrolled in an insurance plan.


Provider: individual who delivers health care services. 


Policyholder: purchaser of an insurance policy; in group health insurance, this is usually the employer who purchases coverage for its employees.


Deductible: the portion of medical costs to be paid by the patient before insurance benefits begin. When a deductible has not been met, payment is collected at the time of service and that amount is reported to the insurance company to be applied to your deductible.


Co-payment: the monetary amount to be paid by the patient, usually expressed as a dollar amount. A co-pay is collected at the time of service and is the same for each physical therapist visit, even if the charges submitted to the insurance company differ from visit to visit. 


Co-insurance: the monetary amount to be paid by the patient, usually expressed as a percentage of charges. This amount is determined by the insurance company’s allowed amount, and is typically billed to the patient after receiving services.


Out-of-Pocket: money the patient pays toward the cost of health care services. 


Eligibility: the process of determining whether a patient qualifies for benefits, based on factors such as enrollment date, pre-existing conditions, valid referrals, etc. 


Reimbursement: refers to the payment by the patient or insurer (third-party) to the health care provider, for services rendered.


Whew! Let’s do a self check. Who feels like they are learning another language? Don’t let the terminology associated with insurance scare you – we were all new at this once! And trust me, as healthcare providers, we don’t expect you to be an expert! Our insurance specialists check each individual’s insurance benefits prior to providing care to give the most transparency we can of cost! If you are unsure of your plan’s specifics, contact us to have a complimentary benefit check. 


If you still have questions, you are not alone! Here are some of the most frequent questions we get: 


Does insurance cover physical therapy services?

Most insurances, including Medicare, worker’s compensation and private insurers, pay for Physical Therapy services. Your physical therapist and your insurance company can tell you whether your insurance covers the recommended services. You can see what insurance we accept at Elite Physical therapy here. If you do not see your insurance carrier listed, please call our office – we are a preferred provider for more companies than we can list!


What if your physical therapist doesn’t participate in your insurance plan?

Most insurance companies allow members to go “out of network” (OON) for health care services. Going OON means that you chose to see a physical therapist who is not a participating provider with your insurance company. In most cases, the amount paid by the insurance company will be less, and you will be responsible for paying the difference in the charges and what the insurance company pays. Many patients choose to receive services OON in order to see the provider of their choice. 


What if you don’t have insurance?

If you don’t have insurance that covers Physical Therapy, you can still receive services from a physical therapist by paying for the services directly. If cost is a barrier, you may want to ask your physical therapist to modify your program with more focus on performing treatment on your own. Ask about establishing a payment plan so that you can get the care you need when you need it most. 


Have additional questions about your health insurance and physical therapy? Elite Physical Therapy is dedicated to help patients get the best, most cost effective care faster by lowering the barrier to PT entry. We aim to provide transparency to patients regarding insurance and cost throughout their time with Elite Physical Therapy. At Elite Physical Therapy we make patients an active part of their plan of care, including as it applies to their insurance! Contact us today to learn more and begin your journey with Elite Physical Therapy!