As helpful as physical therapy can be, not all health insurance plans cover it.
What is true of many kinds of health care is true here, too: some health insurance policies cover physical therapy and some don't. Also, some health plans cover some types of physical therapy but not others.
Does your health insurance cover physical therapy? We will help you figure that out in this article, which discusses:
- How job-based health insurance plans cover physical therapy
- How Obamacare plans cover physical therapy
- How Medicare covers physical therapy
- How much physical therapy costs
How do different health insurance plans cover physical therapy?
Whether or not your health insurance plan covers physical therapy costs depends on several factors.
A major factor is the type of health plan you have. For example:
- Employer-sponsored or job-based policies are more likely than most kinds of health insurance policies to pay for physical therapy.
- Individual health insurance policies, especially ones that are bought from the federal or state marketplace, often cover physical therapy, too. But they don't always cover it well.
- If you're on Medicare, you're in luck. Medicare Part B covers many forms of physical therapy — to an extent.
- People on Medicaid aren't as lucky. Federal law treats physical therapy as an "optional benefit" in terms of this program. That means states can choose to cover it or not. Some do, but many don’t.
Keep reading to learn more about how these different health insurance plans do and don't cover physical therapy.
How does job-based health insurance cover physical therapy?
If you get health insurance from an employer, it will likely cover physical therapy visits and costs.
Large employers, especially, have long included coverage for physical therapy in their health plans to attract talent and compete with other companies and organizations.
The same hasn't always been true of smaller employers, but that's all in the past now thanks to the passage of the Affordable Care Act, also called the ACA or Obamacare, in 2010.
How did Obamacare change things when it comes to physical therapy coverage? The most noteworthy and relevant example is that the law established something called essential health benefits (EHBs). They include:
- Ambulatory patient services (care you get without being admitted to a hospital)/
- Emergency services.
- Pregnancy, maternity and newborn care.
- Mental health and substance use disorder services.
- Prescription drugs.
- Rehabilitative and habilitative services and devices.
- Laboratory services.
- Preventive and wellness services, as well as chronic disease management.
- Pediatric services, including oral and vision care.
All health insurance plans sold through the federal marketplace or the state exchanges must cover these 10 categories of services. Small group plans — those for businesses with 50 or fewer employees — must cover them, too.
The "rehabilitative and habilitative services and devices" category includes physical therapy. This means almost all small group health plans, as well as those sold through the marketplaces Obamacare created, now have to cover physical therapy in some form or fashion.
Don't take this to mean all small group health insurance plans fully cover or pay for all kinds of physical therapy. A few still don't have to cover it all — if they're considered "grandfathered." (Grandfathered plans are ones that existed before the ACA was enacted in 2010.)
Even the small group health plans that do have to cover physical therapy, though, are likely to differ in how they cover it. Although they can't put dollar limits on this kind of coverage thanks to the ACA, they're still allowed to set limits on how often or how many times a policyholder receives treatment.
As for larger employers' health plans, there's nothing but competition keeping them from placing various caps, limits or other restrictions on this kind of care. Because of this, don't sign up for job-based health insurance assuming it will cover all of your physical therapy costs.
Find affordable medical coverage for physical therapy.
Get peace of mind by comparing health insurance plans.
How do Obamacare health insurance plans cover physical therapy?
All health insurance plans sold through the federal marketplace or the state exchanges must cover physical therapy to some extent.
This doesn’t mean all Obamacare health plans cover all forms of physical therapy, or cover them fully. Thanks to the ACA, Obamacare plans:
- Can't put dollar limits on the care you receive from a physical therapist.
- Can cap how many times you visit a physical therapist.
- Can restrict which treatments are covered.
- May only reimburse you for visits to physical therapists if you use in-network providers.
In other words, you may still need to pay 100% of the costs associated with your physical therapy if you have an Obamacare plan.
The amount you pay has to count toward your plan's deductible or coinsurance, but that's pretty much all the law requires here.
Does Medicare cover physical therapy?
First, the good news: Medicare Part B helps pay for physical therapy. It also helps pay for occupational therapy and speech-language pathology services.
Now for the not-so-good news: for Medicare Part B to cover even part of your physical therapy costs, you can't receive treatment while admitted to a hospital. It must be "medically necessary," too.
Therapists and other care providers must tell you if they think Medicare won't pay for a service or treatment. This usually happens if they think a service or treatment isn't medically reasonable and necessary for you. After you get this "Advance Beneficiary Notice of Noncoverage," you can choose to go ahead with the therapy or not. Just know that if you agree to receive care in this situation, you'll probably have to pay out of pocket for it.
When and how does Medicaid cover physical therapy?
Some state Medicaid programs cover physical therapy. Others do not.
How is this possible? Although the federal government manages Medicare, individual states manage Medicaid.
Because of this, your state may choose to cover physical therapy as a Medicaid benefit, or it may not.
Unfortunately, even if your state's Medicaid program currently covers physical therapy, that's no guarantee it will continue to cover it in the future. Legislators at both the federal and state level often target Medicaid spending while working to curb or control health care costs.
What can I do if my health plan doesn't cover physical therapy?
The first thing you can do if your health insurance plan doesn’t cover physical therapy is talk with someone at the company that provides your coverage.
If you can't convince your insurance provider to pay for your physical therapy, tell your therapist about your situation and see if they'll work with you on what they charge. Ask for a discount that's equal to what they'd write off if you had insurance. Or offer to pay on the spot and in cash, which keeps them from having to bill you and saves them money in other ways, too.
Something else you can do if your health plan doesn’t pay for physical therapy: contact colleges and community clinics in your area. Some provide this kind of care free of charge. Others will charge less than your typical therapist does.
If Obamacare is repealed, could it impact how my health insurance plan covers physical therapy?
Yes, if Obamacare is repealed and replaced, it could affect how your health plan covers physical therapy. This is especially true if you bought your policy through the federal marketplace or a state exchange, or if you get your health insurance from a small employer.
Obamacare requires these plans to cover 10 essential health benefits or EHBs — one of which is physical therapy. Many of the Obamacare replacements legislators have proposed to date removed the EHB requirement. Should one of them become law, states could decide which benefits are essential and which aren't. That would put coverage of things like physical therapy in jeopardy for many Americans.
Some experts say this could impact other types of health plans, too — even those provided by large employers. Specifically, it could prompt certain insurers to scale back coverage in various areas, including this one, to raise profits or to rein in spending.
How much does physical therapy cost?
If you have health insurance, you'll probably have to cover a copay of $10 to $50 per physical therapy session. Some plans won't kick in until you reach your deductible, though, which could add to your costs. Another factor to keep in mind: if you receive this care outside your insurer's network, you'll pay more than if you get it from an in-network provider.
If you have to pay out of pocket for physical therapy, expect to pay at least $50 and as much as $350 or more per session. How much you pay in this situation depends on several factors, so do your research and ask plenty of questions before you schedule anything.
How much you or your insurance company pays for physical therapy depends on factors like:
- The type of therapy.
- The length of each session.
- The overall length of treatment.
- The care provider.
The type of physical therapy matters because some types cost more than others. Also, longer sessions usually cost more than shorter ones. And if your rehabilitation or recovery requires you to visit your physical therapist a number of times, the overall cost of your treatment will be higher than if it only requires one or two visits. Finally, different therapists or providers charge different amounts for their services.
Other components that determine how much physical therapy costs:
- Whether or not you need to buy medical supplies or equipment.
- Whether you're treated at an in-network or out-of-network clinic or provider.
- Whether your treatment is done in a clinic or in a hospital.
- Whether you have health insurance or you're paying in cash (out of pocket).
You obviously don't need health insurance to see a physical therapist, but you'll often pay more per visit if you don't have it. This is because insurers negotiate with care providers before settling on a rate. You can do this, too, but it won't always result in a lower bill. Still, it's worth trying if you don’t have health insurance and you need care.
What does physical therapy treat?
Today's physical therapists go far beyond treating bad backs and necks. Here are just some of the ailments and conditions physical therapy typically aids:
- Burns and wounds.
- Carpal tunnel syndrome.
- Chronic obstructive pulmonary disease (COPD).
- Musculoskeletal disorders.
- Pelvic pain.
- Traumatic brain injury.
Physical therapy also can help children with motor development and function. And it often helps people of all ages deal with balance issues or recover from dislocations and fractures.
There is more to physical therapy than relieving pain, restoring function and improving mobility, though. It's also used to:
- Identify and diagnose problems and issues.
- Prevent injuries and disabilities.
- Alleviate chronic disease.
- Reduce the need for prescription medications — especially opiates.
- Maintain overall fitness and health.
And then there's the fact that physical therapy can, and increasingly does, offer an alternative to surgery.
QuoteWizard.com LLC has made every effort to ensure that the information on this site is correct, but we cannot guarantee that it is free of inaccuracies, errors, or omissions. All content and services provided on or through this site are provided "as is" and "as available" for use. QuoteWizard.com LLC makes no representations or warranties of any kind, express or implied, as to the operation of this site or to the information, content, materials, or products included on this site. You expressly agree that your use of this site is at your sole risk.