Understanding Insurance for Physical Therapy

Your insurance plan covers physical therapy, which means you don’t have to pay anything for your appointment, right? Well, in most cases, you will need to pay your deductible and coinsurance or pay a copay. So, what do these terms mean and what does the cost look like?

What is a deductible?
The deductible is the amount you must pay each calendar year before your insurance plan begins to pay. Deductible amounts vary from plan to plan. For example, if your deductible is $500, then your insurance plan will not pay anything until you have paid $500 for services subject to the deductible. What services are subject to the deductible? This varies from plan to plan. Consult your plan benefit booklet for more details.

What is a coinsurance?
Coinsurance is calculated as the percentage of costs of the allowed amount for a covered service that you pay after you've satisfied your deductible. Percentages vary by insurance plan usually ranging from 10% to 50% of covered services.

What is a copay?
Copays are a fixed dollar amount that you pay for a covered service. Copays vary for different plans and types of services. Copays for physical therapy may range from $10 to $50. Since copay amounts are fixed, you will always pay the same amount at each appointment, regardless of visit length. In most cases, copays accrue toward your Out of Pocket Maximum.

What is Out of Pocket Maximum?
The Out of Pocket (OOP) is the maximum amount you would pay out-of-pocket in a calendar year. Once you have met your OOP, your insurance plan pays 100% of the claims for the rest of the calendar year.

What is an “allowed amount”?
The allowed amount is the reimbursement rate set by each insurance company for a particular service code. These rates vary from company to company.

What if I have a secondary insurance plan?
If you have a secondary insurance, the secondary payer usually covers the deductible, coinsurance or copay amount of the primary plan. However, in some cases, the secondary insurance plan also charges a copay, coinsurance, or deductible, so you may still be financially responsible for a portion of the bill. Consult your secondary insurance plan’s benefit booklet for more information.

How much will I owe for each appointment?
Example: Say you are covered by Health Insurance Company A. Company A’s allowed amount for an average health care visit* is $120 and your coinsurance is 20%. If you've already met your deductible, you pay 20% of $120, or $24. The insurance company pays the rest. If you haven't met your deductible, you pay the full allowed amount, $120.
*
The total amount billed to your insurance company will vary from visit to visit, depending on the length of your appointment and which type of service codes your physical therapist bills.

Example: Now, let’s say you are covered by Health Insurance Company B. Company B’s allowed amount for the same health care visit is $132 and your coinsurance is 20%. If you've already met your deductible, you pay 20% of $132, or $26.40. The insurance company pays the rest. If you haven't met your deductible, you pay the full allowed amount, $132.

What if I cannot afford to make my payment at each appointment?
Our office is happy to arrange a payment plan that works within your budget! That way, you can make payments for your treatment over a timeframe that works for you. To set up a payment plan, please ask to meet with our billing specialist.

Staszak Physical Therapy & Wellness Center is located in downtown Eugene and offers appointments Monday through Saturday. Give us a call today to schedule an appointment or if you have any questions. 541-505-8180