Does Insurance Cover Physical Therapy? Part 1

Let’s face it, insurance can be tricky and extremely overwhelming. However, this 3-part blog series by the BeneFIT Billing Extraordinaire, Nathan Forster, is designed to help you understand your physical therapy insurance benefits from the ground up. Firstly, Part 1 will break down insurance terminology. In Part 2, we’ll talk about what being an in network and out of network provider really mean. Lastly, we’ll talk about how BeneFIT Physical Therapy works with insurance to ensure the best possible for our patients!

Terms Relating to Patient Responsibility

Payments made every time you see your PT:

  • Copay: A set amount of money you pay per visit
  • Coinsurance: The amount you owe for a visit based on a percentage of what was deemed covered by your insurance company

ALL PROVIDERS ARE DIFFERENT. Whether you have a copay or coinsurance is entirely dependent on the health care provider’s relationship with the insurance company. This will be explained more in Part 2 & 3.

Short-term payments:

  • Deductible: How much you and/or the members on your plan have to pay out of pocket before the insurance company begins paying. Plans generally have 2 kinds of deductibles: individual and family.
    • Your individual deductible is your personal deductible. Once it has been met, insurance kicks in and starts paying their part for the services you receive.
    • The family deductible generally refers to the total deductible for everyone on the plan. If the FAMILY deductible has been met, but your INDIVIDUAL deductible has not been met, the FAMILY deductible wins out and insurance should start paying!

Some plans have ONLY a family deductible, the entirety of which will need to be paid before insurance begins paying.

The Devil in the details: not all services are automatically applied to your deductible, and it is dependent on your specific plan. Similarly, your deductible does not always have to be met for certain services to be covered by insurance. Does that sound confusing? Absolutely, because it is confusing! Here at BeneFIT, we do a deep dive on your PT benefits to give you the whole picture.

  • Out of Pocket Max: This is essentially a ceiling effect. It is the maximum you pay out of pocket before your insurance company covers 100% of costs. Depending on the plan, your deductible could be included in this.

Terms Relating to Patient Access to PT

  • Visit Limits: Some insurance plans limit the amount of physical therapy you can receive in a year. Don’t worry! Here at BeneFIT we work with you and your goals to optimize your time here and make the most of your visits, whether you have 30 or 300 of them.
  • Direct Access: While not directly an insurance term, it’s a good one to know! In the State of New Jersey, you do not need a prescription to see a physical therapist. This is because Physical Therapists are doctors! Read more about it in our Direct Access blog post HERE.

Try it Out: Take a look at your Health Insurance benefits. What are your deductible & out of pocket maximum?

Contact Us!

If you would like to learn more about about BeneFIT or physical therapy, give us a call or check us out on Instagram today! New Jersey has direct access which means you can come see us without seeing your doctor! We can see you quicker than you could get in to see the doctor, while also saving you both time and money!  

Please, call us to schedule your evaluation at one of BeneFIT’s locations, Bridgewater (908.203.5200) or Chester (908.879.5700)  with one of our highly trained Doctors of Physical Therapy!