How to Pay for Physical or Occupational Therapy

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Addie Morgan, a software account executive and part-time wedding planner in Atlanta, has a problem that some women would love to have -- she can only walk in high heels. But it's not because she thinks she's the next Beyonce. It's because of an inflamed Achilles tendon.

Morgan went to her doctor about it. "He said that other than giving me an injection, the best thing was to go to physical therapy and see how I did with it," she says. Her insurance plan offered 30 sessions a year. She had to pay $30 for each appointment. The insurance company paid the rest.

Her payment method is pretty typical. Under the health reform law known as the Affordable Care Act, insurance plans offered on your state's health insurance marketplace need to include coverage of rehab like physical, occupational, or speech therapy.

To get physical therapy, you don't always need to be referred by a doctor. "We have direct access in all 50 states," says Carmen Elliott, vice president of payment and practice management at the American Physical Therapy Association. "However, an insurance company could still require that you get approval from a doctor before beginning treatment."

For occupational therapy, which helps you with skills for daily life like dressing, eating, and showering, "most insurances require a physician referral," says Christina Metzler, director of public affairs for the American Occupational Therapy Association. "It's their way of making sure that people get the right services. But some states allow people to go directly."

Sometimes your kids are able to get some types of therapy in school, without any cost to you. "Children can get occupational therapy if they're in special education and that's paid for by the schools," Metzler says.

Medicare and Medicaid

Medicare is the government insurance program for seniors and some younger people with disabilities. It typically pays 80% of the therapy cost and you pay the rest. If you have the supplemental insurance called Medigap, you'll get the whole bill paid for. Keep in mind that there's a dollar limit for these services. Once you hit it, the cost is all yours, though you're allowed to appeal for more coverage.

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If you have a type of Medicare coverage called "Medicare Advantage," the coverage works a little differently. Instead of having to pay 20% of the bill, you pay a fixed amount -- called a co-pay -- for each visit.

If you have a low income, you might use the government program called Medicaid to pay for your medical bills. Each state sets its own polices. Some cover rehab, some don't. Or some may pay for children, but not adults.

Check the Plan

So what should you look for in your insurance policy before going for therapy treatments? Here are a few things to keep in mind:

If you think you might need therapy, see how many visits are included in your coverage. Health plans can vary. For instance, yours might say you get 12 appointments, but that might be split between all types of rehab. So if you needed both physical and occupational therapy, you might come up short.

Be sure that the specific service your physical or occupational therapist wants to do is covered by your insurance. Not all of them are. Even if it's not covered, Metzler says it's sometimes worth submitting the bill to your insurance company anyway, and then appeal the decision if they won't pay.

WebMD Feature Reviewed by Jennifer Robinson, MD on February 16, 2016

Sources

SOURCES:

Addie Morgan.

Carmen Elliott, vice president of payment and practice management, American Physical Therapy Association.

National Conference of State Legislatures: "State Health Insurance Mandates and the ACA Essential Benefits Provisions."

Healthcare.gov: "What Marketplace Health Insurance Plans Cover."

Christina Metzler, director of public affairs, American Occupational Therapy Association.

Medicare.gov: "Physical Therapy, Occupational Therapy, Speech Therapy Services," "What's Medicare Supplement Insurance (Medigap)?"

Kaiser Family Foundation: "Medicaid Benefits: Physical Therapy Services."

American Physical Therapy Association: "Physical Therapy and Your Insurance."

Healthinsurance.org "How is Autism Covered Under the Affordable Care Act?"

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