OC Sports & Rehab

Does Insurance Cover Physical Therapy

“Does Insurance Cover Physical Therapy?” is a common question we get asked. For many people, physical therapy is a critical component of their medical care, whether it’s to recover from an injury or prevent degenerative conditions from worsening. Unfortunately, the effectiveness and importance of physical therapy don’t always mean it is affordable, and many Americans will have to rely on their insurance provider to be able to access this care. It can sometimes be difficult to understand what exactly your plan covers and how much you may owe for physical therapy. While the answer is different for everybody, there are some questions you can ask to determine what this coverage may look like for you.

Physical Therapy and Insurance Plans

Any health insurance plan that is compliant with the Affordable Care Act (ACA) and other state-marketplace regulations is required to offer ten “essential benefits.” By law, these plans must cover anything that counts as one of these ten benefits. One of these categories is rehabilitative services, which can include physical therapy. In addition to these plans, any federally qualified HMO plan should cover physical therapy.

When it comes to other private insurance, there are three possible scenarios: physical therapy is covered with a co-pay from you, physical therapy is covered and you pay a co-insurance and/or deductible, or physical therapy isn’t covered and you will have to pay out of pocket. In some cases, which scenario applies to you will depend on the reason for your physical therapy.

For example, your plan may not cover physical therapy as a preventative treatment related to athletic endeavors, but it may cover the service if you are recovering from surgery.

Questions to Ask Your Insurance Provider About Physical Therapy

Health insurance plans can be difficult to understand. Before you begin any treatment, it’s a good idea to reach out to your insurance provider for clarity on what exactly your coverage will look like. This can help you avoid surprise bills or even a denied claim.

  • What providers are in-network?
  • What is the maximum amount they will pay?
  • What is the deductible and out-of-pocket maximum?
  • Is there a limit to the number of visits?
  • Do you need a referral?