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How much physical therapy will your health insurance cover?

 

Tamara E. Holmes

If you’ve ever undergone major surgery, you know that a health crisis can be difficult to bounce back from. Fortunately, physical therapy, a type of treatment that can relieve pain and improve your mobility, often can get you back on your feet much faster, particularly if your health insurance plan picks up the tab.

Physical therapy can help you better perform many day-to-day activities, such as walking or climbing up and down stairs. Physical therapists may use techniques such as exercise and massage to improve your physical condition. Most health insurance plans will pay for some physical therapy if policyholders need it, says Jim Nugent, a senior policy analyst for the American Physical Therapy Association, which represents more than 85,000 physical therapists. However, insurers differ on how much they’ll pay for physical therapy and how long a policyholder can have it.

Some insurers require a referral from a doctor. For example, Aetna considers physical therapy to be a necessity as long as it’s prescribed by a physician and significantly improves physical functions that were limited because of a disease, illness or surgical procedure.

On the other hand, Aetna does not consider physical therapy to be necessary for someone whose condition is getting worse or if the patient is not showing improvement. Other insurers place a dollar limit on how much they’ll pay for physical therapy. For example, Medicare caps physical and speech therapy combined at $1,900 a year (2013). If your physical therapy costs exceed that, you’ll have to pay for it yourself.

Some states impose guidelines and caps on how much physical therapy coverage an insurance plan must offer. For example, Vivian Laxton, a spokeswoman for the Maryland Insurance Administration, points out that in her state, every health insurance plan must cover at least 30 “medically necessary” visits each year. The time to find out how much physical therapy your health insurance plan would pay for is before you need it, Nugent says.

Here are three tips on how to make sure you have enough physical therapy coverage:

  1. Find out about physical therapy benefits before signing up with a health plan. Look for a health insurance plan that gives you at least 20 physical therapy visits per condition each year, Nugent says. While some people might need more physical therapy than that because of a serious illness, 20 visits will make a big difference for most patients.

  2. Ask a physical therapist what insurance plans are accepted. If you know someone who’s getting physical therapy or you know you’ll need physical therapy after an upcoming procedure, contact the physical therapist first to see which health plans are accepted and choose your insurer that way, Nugent says.

  3. Be willing to fight a denied claim for physical therapy. “In health care, the squeaky wheel gets the oil,” Nugent says. Don’t be shy about contacting your insurer and asking why it won’t pay for physical therapy or why it won’t cover it for as long as you need. Every insurer has a process for appealing a denied claim. If you make a strong enough case, you might be able to change your insurer’s mind.
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