Open enrollment for health insurance is here, and if you’re like most people, you may be feeling a bit overwhelmed. Whether you’re recovering from an injury or just looking to stay proactive about your health, picking the right insurance plan can make all the difference—especially when it comes to physical therapy.
We know it’s tough to sort through all the insurance jargon, so we’re here to help you cut through the confusion.
This guide will walk you through some key things to look for when choosing a new plan, specifically if you want to work with out-of-network providers.
In-Network vs. Out-of-Network: What’s the Difference?
The first thing you need to know is the difference between in-network and out-of-network providers. If you choose an in-network provider, your insurance company has a pre-negotiated rate with them. This means no matter how long your appointment is, the rate stays the same. However, with in-network providers, you might get less face-to-face time with your physical therapist because of these set rates.
On the other hand, out-of-network providers, like us at Myokinetix, don’t have a contracted rate with your insurance. This allows us to spend more time on personalized care for you. While it might seem more expensive upfront, it could mean more comprehensive, one-on-one attention that helps you recover faster.
Understanding Deductibles vs. Out-of-Pocket Maximums
Now, let’s talk about deductibles and out-of-pocket maximums (OOP max)—two key terms that can affect your physical therapy costs.
- Deductible: This is the amount you have to pay out-of-pocket before your insurance kicks in to cover a percentage of your medical expenses. The lower your deductible, the sooner your insurance starts helping you out. If you plan to attend a lot of therapy sessions, opting for a lower deductible might save you money in the long run.
- Out-of-pocket max: This is the maximum amount you’ll pay for covered services during your policy period. Once you hit this amount, your insurance will pay 100% of your medical costs for the rest of the year. A lower OOP max means less worry about surprise bills.
Understanding these two terms can help you balance your budget while still getting the care you need for recovery.
Copays vs. Coinsurance: What You’ll Pay
When working with in-network providers, you’re probably familiar with copays—a fixed fee you pay at each visit. For out-of-network providers like Myokinetix, you’ll likely encounter coinsurance, which works a bit differently.
- Coinsurance: After you’ve met your deductible, coinsurance is the percentage of the bill that you’re responsible for. For example, if your coinsurance is 70/30, your insurance will cover 70% of the cost, while you’ll pay the remaining 30%. The higher the percentage covered by insurance, the better.
If you’re opting for out-of-network care, look for a plan that offers a high insurance coverage percentage to reduce your out-of-pocket expenses.
Visit Caps and Cap Amounts: What to Watch Out For
You may come across terms like visit cap and cap amount when reviewing your insurance plan. These are limits your insurance places on the number of visits and the amount they’ll pay per visit.
Visit cap: This is the limit on how many therapy sessions you can attend in a policy period.
- Unlimited: Visits are allowed as long as they’re medically necessary.
- Soft cap: You’re allowed a certain number of visits, but more can be approved if necessary.
- Hard cap: You can’t go over a set number of visits unless there’s a major medical emergency.
Cap amount: This is the maximum amount your insurance will reimburse per visit. For example, if your insurance has a cap of $52 per visit, but your session costs $75, you’ll be responsible for covering the extra $23.
Keep an eye on both the visit cap and cap amount when choosing your plan—especially if you expect to need ongoing physical therapy.
Do You Need a Prescription for PT?
In some cases, your insurance may require a prescription from a doctor before covering your physical therapy. Fortunately, New Jersey is a direct access state, meaning you can start physical therapy without a physician referral. However, after 30 days of treatment, if more sessions are needed, you may be required to see a doctor for further approval.
Key Takeaways: Choosing the Best Insurance Plan for Your Recovery
So, how can you ensure your insurance plan will cover the care you need, whether it’s with us at Myokinetix for physical therapy, or with another out-of-network provider?
Here are a few green flags to look for:
- Strong out-of-network coverage: This will allow you to access higher-quality care without being limited to in-network providers.
- Low deductible and out-of-pocket max: The lower these numbers are, the sooner your insurance will start covering the bulk of your treatment.
- Favorable coinsurance rates: The higher the percentage your insurance covers, the less you’ll have to pay.
- No or soft visit caps: Ensure you’re not limited in the number of sessions you can have, especially if you’re recovering from an injury.
Conclusion
By choosing the right insurance plan, you can ensure that you get the quality care you need without unnecessary financial stress.
At Myokinetix, we’re committed to providing the highest level of care for athletes and individuals looking to recover from injuries. As an out-of-network provider, we offer flexibility in our treatment plans, allowing us to spend more time with each patient.
Have questions about your insurance or want to get started on your physical therapy journey? Book a call with us today—we’re here to guide you every step of the way.