PT Patient’s Guide to Choosing An Insurance Plan

October 19th, 2018

Tips for Choosing an Insurance Plan

Whether you’re shopping for your own insurance or going through the benefits selection process with your employer, choosing the right plan can seem like an overwhelming task. While we can’t tell you which specific plan to choose, the following questions should help you with the selection process.

Questions to Ask Potential Insurance Carriers

What is my premium?
This is the monthly amount you pay for coverage. The lower it is, the higher your deductible will typically be. Plans with low premiums and high deductibles often are called “catastrophic” plans. Conversely, higher premium plans often feature lower deductibles, copays, and coinsurances.

What is my deductible, and what does it apply to?
This is the total amount you must pay each year before your insurance begins to pay. For example, if your deductible is $4,000, then you must pay $4,000 toward deductible-applicable services before your insurance will pay anything. If your deductible applies to PT services, then you may have to pay anywhere from $100-$150 per visit until you meet your deductible. Once you reach your deductible, your copay or coinsurance will apply.

What is my copay?
High copays are another common drawback to low-premium plans. Remember, the copay applies even after you have met your deductible, and the copay for specialist visits—including PT visits—can be as high as $80. So, if you anticipate a lot of office visits during this plan year, you will definitely want to factor the copay into your decision process.

What is my coinsurance?
As previously noted, coinsurance is another version of cost-sharing. So, you’ll likely have to pay either a coinsurance or a copay. However, while copays are fixed amounts—and thus, are more predictable—coinsurances are percentages. Therefore, your financial responsibility varies based on how much your provider charges for the services rendered.

Are there any restrictions on the types of providers I can see?
Some insurance plans (e.g., PPOs, HMOs, and EPOs) are limited to a certain network of providers. So, make sure you have a good selection of covered providers and facilities in your area. If you travel frequently or live in a rural area, you may want to choose a plan that has no network restrictions.

Do I have to get a referral to see a specialist?
If your insurance plan requires you to obtain a referral before seeing a specialist (e.g., a physical therapist), and you fail to do so, the insurance company may deny coverage for services rendered. So, if you do not want to go through a primary care provider (e.g., your family physician) each time you want to see a specialist, make sure your plan does not require a referral (a.k.a. prescription) for specialist services.

How many visits of “X” am I allowed each year?
In this case, “X” represents a specific type of service (e.g., physical therapy, occupational therapy, or chiropractic). Some plans place a limit on the number of covered visits per year (e.g., 20 visits), while others allow for unlimited visits. If you’re athletic, have chronic joint pain, or anticipate needing a joint replacement in the near future, you may not want any restrictions on the number of rehabilitative visits allowed.

For Medicare secondary payers: Will this plan cover the entire 20% not covered by Medicare?
Medicare only pays 80% of the cost of care, so many Medicare beneficiaries seek secondary insurances to pay the other 20%. However, even those plans often feature deductibles, copays, coinsurances, or visit limitations. Thus, we recommend posing all of the questions listed above to any secondary insurances you are considering.

The Bottom Line

Higher-premium plans are generally better for individuals who expect to receive medical care on a regular basis. Lower-premium plans will save those individuals money monthly, but those savings won’t make up for the cost-sharing portion.

How can Physical Therapy of Melissa help?

Our patient referral coordinator is available to help you understand plan costs. PTM knows the allowable amounts for all insurances where we are in-network and can help you determine the specifics of deductible and coinsurance amounts for our services.

How your accrued deductible and out of pocket amounts are applied
PTM’s referral coordinator can access the details of any plan to determine if your accrued payments cross-apply to in and out of network providers. Certain plans also allow any accrued amounts for pharmaceuticals to apply toward your out-of-pocket maximum.

What does cross-apply mean?
If you have in and out of network benefits you may have different deductible, copay, coinsurance, and out-of-pocket maximum amounts for in network vs. out of network. If a plan cross-applies, you receive the same credit toward your in network accrued amounts as your out of network accrued amounts. If a plan does not cross-apply you would not receive credit toward the accrued amount paid to an out of network provider toward your in network deductible.

  • Example 1: PTM is out of network, but your accruals cross-apply. Anything you pay here in deductible or coinsurance you are also getting credit toward your in-network accruals.
  • Example 2: PTM is out of network and your accruals do not cross-apply. Anything you pay here in deductible or coinsurance is only going toward your out of network accruals.