As we approach the final weeks of 2019 and look ahead to the new year, clients often approach the Impact Physical Therapy of Hillsboro / Banks team with some version of the same question:
“As I consider health insurance plans for 2020, how do I ensure I select a plan that’s not only affordable, but also provides coverage for physical therapy services?”
The fact that this question is being asked is great news when it comes to patient empowerment in health care.
It is an indicator that people want to become more educated about the options available to them insurance-wise. In addition – whether they’re looking to acquire private insurance, health insurance through an employer, or are considering options in Medicare – it indicates people are also recognizing the valuable role physical therapy can play in ensuring they live long, active and healthy lives.
“Patients find the best success in health care when they can advocate for themselves,” said Laura Perry, a Doctor of Physical Therapy at Impact Physical Therapy of Hillsboro and Banks.
“Unfortunately,” she added, “we regularly encounter people who are confused by their health insurance benefits and have very poor literacy when it comes to understanding even basic plan terms.”
To help clear this confusion, and to help further empower patients to become better advocates of their own health care journeys, Perry offers definitions of the following relevant terms – basic aspects of insurance that are commonly misunderstood:
Deductible: This is the amount you must pay for your health care services before your health insurance kicks in to help cover costs. If your deductible is $1,500, for instance, you must pay $1,500 for eligible health care services before insurance begins to pay. Once your deductible is met, you start paying coinsurance.
Coinsurance: Coinsurance is your share of the costs for health care services after your deductible is met. The rest is paid by your insurance provider. Coinsurance is usually determined as a percentage of services. So, if your plan covers 75% of a service (after deductible’s met), your coinsurance is 25%.
Copay: Copay is a fixed amount that you pay for a particular health care service. This payment is typically made at the time of said service, and the amount varies by service. For example, your provider may charge a $40 copay for a physical therapy visit. Depending on your plan, copays may apply immediately or only after your deductible is met.
Out-of-Pocket Maximum: When combining deductibles, coinsurance and copay costs, the “out-of-pocket max” is the most you have to pay for covered health care services over the duration of the plan. Once you’ve reached your out-of-pocket maximum, insurance covers 100% of all covered services. (Note: This does not include monthly premiums.)
Out-of-Network Providers: When an insurance company has a contract with a physician, physical therapist, hospital or other provider, they’re considered “in-network.” When they don’t, they’re considered “out-of-network.” Depending on your insurance plan, out-of-network providers may be covered at a higher rate, or they may not be covered at all.
Health Savings Account: Often provided by employers, Health Savings Accounts (HSAs) let you set aside untaxed money from your paycheck, which you can then use to pay for qualifying medical expenses, including deductibles, coinsurance and copays. Since the money isn’t taxed, having an HSA can lower your overall health care costs.
Medicare Therapy Cap: The only thing to know here is that, as of 2018, there is no longer a therapy cap for Medicare. This means that if you have Medicare, there is no longer a cash limit for the amount of medically necessary physical therapy you require to live an active, healthful life.
Utilization Management Companies (i.e., eviCore): Organizations like eviCore are hired by many health care insurance companies to manage the utilization of patients’ physical therapy (and many other) benefits. While your plan may grant you 12 total physical therapy visits, for instance, eviCore may determine that you only get two visits for a particular ailment or injury.
According to Perry, utilization management companies, along with other insurance-based limitations, can create a level of frustration for both patients and their physical therapists. The key to maneuvering through it all, she says, is to have an open and honest conversation with the Impact Physical Therapy team on the very first visit.
This conversation will center around both your insurance coverage and how it best aligns with your full, predicted course of treatment.
“You should be upfront about your coverage while asking questions about how long we think your course of care should take,” Perry said. “If for instance you have a high deductible, it may turn out that there’s no way we’ll meet it through the entire course of care. In this case, you may find it more affordable to go the cash pay route.”
Cash Pay: Perry says cash pay essentially cuts out the “middleman” (i.e., the insurance providers), allowing Impact Physical Therapy to charge a lower rate per visit, which may be advantageous for the patient.
“If we know what we’re up against from the very beginning, we can help you save on health care costs while still providing you with the physical therapy you need,” Perry said. “But, in order to have this conversation, you need to have a firm understanding of your health insurance plan and how it works.”