Insurance Frequently Asked Questions
Before your health insurance policy starts paying benefits, there are usually some costs you’re responsible for – such as your deductible and co-insurance, and/or a co-pay. You probably also have an out-of-pocket maximum. Not sure what all of this means? We define these terms and more below to help you better understand your insurance benefits and how they work.
The information below is for general purposes and is not specific to any one insurance plan or company. Health insurance plans vary, so you should check your contract to see what your deductible, co-pays and co-insurance amounts are. They are sometimes printed on your insurance ID card as well.
What is a "Co-insurance"
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for a visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
What is a "Co-payment"
A fixed amount (for example, $25) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service such as office visit, specialist visit, or hospital-based service.
Co-insurance and co-payments are not the same. A co-payment is the specific amount you pay at each visit, while co-insurance is a percentage of the covered service that you are required to pay. Depending on your plan, you may have to pay both co-insurance and a co-pay for a given visit.
What is a "Deductible"
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $2500, your plan won’t pay anything until you’ve met your $2500 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. A deductible amount is calculated yearly, so you have to meet a new deductible for each year of the policy.
Deductible amounts vary by plan and can be separated into individual or family deductibles. In general, a family deductible is double an individual deductible, but it can include several members of a family.
With a few plans, the deductible and out-of-pocket maximum are the same dollar amount. With most plans though, you will be responsible for either a co-insurance or a co-payment after the deductible is met and until the out-of-pocket maximum is met.
What is an "out-of-pocket maximum"
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $2500, your plan won’t pay anything until you’ve met your $2500 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. A deductible amount is calculated yearly, so you have to meet a new deductible for each year of the policy.
Deductible amounts vary by plan and can be separated into individual or family deductibles. In general, a family deductible is double an individual deductible, but it can include several members of a family.
With a few plans, the deductible and out-of-pocket maximum are the same dollar amount. With most plans though, you will be responsible for either a co-insurance or a co-payment after the deductible is met and until the out-of-pocket maximum is met.
What’s the difference between a prescription and a referral?
Prescriptions
You can always have an initial evaluation without a prescription. Some insurance plans do not require you to have a prescription to cover physical therapy services, but most plans require you have a prescription (or signed plan of care) before treatment will be covered. Whatever the prescription requirements of your plan, the Pennsylvania State Practice Act for Physical Therapists states that a patient can be treated only for up to 30 calendar days without an order from a physician, PA, or CRNP. Any treatment beyond 30 days requires an prescription (or signed plan of care) from a physician, PA, or CRNP.
Referrals
A request that is electronically submitted by your Primary Care Physician’s (PCP) office to your insurance company. The insurance company will either approve a specified number of visits to occur within a specified timeline, or they will deny the request.
Why do I need a prescription or order if I’m paying out of pocket?
The Pennsylvania State Practice Act for Physical Therapists states that a patient can be treated for up to 30 calendar days without an order from a physician, PA, or CRNP. Any treatment beyond 30 days requires an order from a physician, PA, or CRNP.
Why do I need to be re-evaluated during my episode of care?
First, Pennsylvania code requires that a re-evaluation be performed every 30 calendar days.
Second, and more importantly, a re-evaluation gives objective evidence of how your therapy is progressing. The physical therapist uses the information gained from the re-evaluation to determine what, if any, changes should be made to your plan of care, or if you’re rehabilitated and ready to close out your episode of care or transition into a wellness program.
I was evaluated the last time I was treated here, why do I need to have another initial evaluation?
Any time an episode of care is discharged, an initial evaluation is necessary in order to open a new episode of care both for insurance coverage and for effective treatment. Your condition in terms of strength, range of motion, and movement patterns may have changed substantially since your previous episode of care. In order to create an effective treatment plan, the therapist needs to see your current physical status.
Why does the cost per visit vary?
If you have a deductible and/or co-insurance responsibility, your cost per visit may vary depending on what services are provided each day. In general, 1 unit of a procedure code is billed every 15 minutes. We use about 8 different procedure codes plus the codes for evaluations and re-evaluations. Each procedure code has a slightly different contracted reimbursement rate which each different insurance compnay. Depending on which procedure codes are billed, how many procedure codes are billed, and in which combinations, the cost will vary.
How do I read my patient statement?
Difference between billed charges, allowed amounts/contracted/negotiated rates.
How do I know how many visits my insurance allows?
Read your financial policy before you sign it, or contact your insurance directly.