Here are some useful definitions and information to help you understand your insurance coverage:
DEDUCTIBLE: A deductible is the amount you pay for healthcare services before your health insurance begins to pay their contracted amount.
For example, if your deductible is $1,000, you must pay for health services rendered until that full amount in billable health services is reached. After that, you will typically share the cost with your plan by paying coinsurance and/or co-pays before your insurance company begins to pay a contracted portion for your health care service.
COPAYMENT: A copay is a fixed amount you pay for a health care service, which can vary by the type of service. You may also have a copay when you get a prescription filled. Physical therapy copays tend to range between $20 and $50. Copays are due at the time of service.
COINSURANCE: Once your deductible has been met, your insurance company will begin paying for a percentage of your care, and you will be responsible for coinsurance. Coinsurance is your share of the costs of your health care service after your insurance pays their portion. For example, once your deductible is satisfied, if the covered charges are $300 and if your co-insurance ratio is 80%/20%, your insurance company will pay $300x.80=$240, and you will be responsible for $300x.20=$60. When you call your insurance to verify your benefits, the coinsurance rate quoted is usually the percentage that the insurance company will pay.
OUT-OF-POCKET MAXIMUM: After you have paid this total dollar amount in copayments, deductibles, and co-insurance, your insurance will pay 100% of the cost of all covered services (often up to a stated maximum).
PRECERTIFICATION/PREAUTHORIZATION: Most insurance plans now require precertification for physical therapy. This means that, based upon your individual case and the data submitted by your therapist (your pain level, loss of strength and motion, etc.), your insurance company will determine in advance how many visits will be covered. Once those approved visits are completed, it is typically possible for the therapist to submit updated data to get approval for another set of PT visits*.
*Please note that some insurance companies require that the set of approved visits be used by a certain date. Even if your insurance company allows a certain number of visits per plan year, not all of these may be granted based upon the status of your case and progress that is made in physical therapy.
Please remember that these are basic guidelines and that every insurance company and plan has different and specific nuances. When in doubt, contact your insurance company directly to obtain details about your specific plan. (It is always a good idea to contact your insurance company directly to verify).