Insurance plans that cover occupational therapy vary between private insurers, employer-sponsored plans and Medicare. Coverage varies based on plan type and may include deductibles, copayments and/or coinsurance charges.
Original Medicare Part B provides better occupational therapy coverage than most health insurance plans; however, visits are still limited and medical documentation must be submitted.
How to Find Out
Health insurance is essential, and having coverage that includes occupational therapy treatments is especially essential. Unfortunately, it’s often impossible to find plans that cover 100% of treatment costs; instead there may be deductibles or copays associated with each session, with the total costs depending on individual insurance policies.
First step to determine whether occupational therapy coverage exists is reviewing your insurance policy, either online or over the phone, depending on your preference. Be sure to look out for details such as deductibles, copays and coinsurance as well as limits or exclusions that might apply.
Once you are familiar with your health insurance coverage, meet with an in-network occupational therapist to discuss the cost of each visit and any expected expenses. Ask about flexible payment plans or financing options they might provide so it will be easier for you to afford treatment; additionally inquire as to any Employee Assistance Programs provided by your employer.
Not to be forgotten is that some insurance policies set limits on how often an OT practitioner may be seen annually; once this limit has been reached, additional sessions no longer fall under their coverage and patients must bear full cost of each session from that point forward.
If your health insurance denies coverage for an occupational therapy (OT) session, filing an appeal may be the solution. Depending on what type of policy you have and the process involved in appealing will differ; original Medicare users can use their Medicare Summary Notice every September as the way to do it while those enrolled in Medicare Advantage plans need to contact customer service for their provider to file.
Deductibles and Copayments
Cost of therapy treatment depends on two key components of an insurance plan’s deductible and copayments: each year an insured person must meet an annual deductible before their insurer begins covering costs; for example Medicare Part A has an annual deductible of $1,484. Once this amount has been met, Medicare begins covering 80 percent of covered services’ costs; copayments are fixed dollar amounts that an insured must pay every time they receive therapy – for instance Medicare Part B requires between $20-$50 copayment for occupational therapy visits.
Many insurers require you to meet a deductible or copayment before occupational therapy can be covered; thus it is crucial that you understand these cost structures before signing up for any health plan.
Insurance plans typically cover occupational therapy sessions, with coverage varying by plan. Some plans will only reimburse full cost after meeting certain treatment sessions or conditions are fulfilled, others tie continued coverage to members showing improvement in symptoms and functioning, and still others only pay for limited sessions before discontinuing coverage altogether.
Insurance plans typically recommend that members use in-network occupational therapy providers for optimal cost control and coverage expansion. Insurers vetted and approved providers help control costs while increasing coverage. If allowed by your plan, however, out-of-network benefits may have different reimbursement rates and coverage limits than their in-network equivalents.
Although most insurance plans cover occupational therapy, it’s wise to shop around for one that best meets you and your family’s needs. Plans can have vastly differing cost structures depending on deductible, copayment and coinsurance amounts; additionally some plans will have additional exclusions that need to be aware of.
Original Medicare (Parts A and B) typically offers more comprehensive occupational therapy coverage than most marketplace or employer-based health plans, though even if your plan includes occupational therapy coverage you should still consider switching for greater savings.
Limits and Exclusions
Dependent upon your health insurance plan, there may be limitations and exclusions preventing you from accessing occupational therapy coverage. These could include deductibles, copayments and coinsurance amounts as part of the total cost of care; they all add up quickly! Furthermore, certain plans require preauthorization or referral from your physician prior to beginning treatments; in these instances you will want to obtain this document prior to commencing care.
Most insurers, including Medicare, encourage their customers to seek in-network providers whenever possible to lower costs and expand coverage. Each insurance provider typically has a list of approved providers; when searching out-of-network occupational therapy services it would be prudent to stick with those on this list when possible. In-network providers usually charge significantly less than out-of-network ones.
Medicare sets an annual maximum number of outpatient occupational therapy visits for each condition that it will cover; after this limit has been reached, insurance will no longer cover any further services until the new benefit year begins – known as the threshold amount and index by Medicare Economic Index (MEI). It does not apply to people covered by a Medigap supplement policy.
Medicare’s 8-minute rule for outpatient occupational therapy stipulates that you see your therapist for at least eight minutes during each visit, though this doesn’t apply to people covered by Medigap policies that cover Original Medicare Part B deductibles.
Some occupational therapists are required to obtain professional liability insurance in order to guard themselves from malpractice lawsuits, which can add another expense. Proliability provides cost-effective professional liability coverage that puts both you and your patients first, so you can focus on doing what’s important while not having to worry about financial risks associated with a malpractice suit. Reach out today and discover more how we can assist your OT practice secure the coverage it needs for success!
Out-of-Network Providers
Health insurance providers typically form contracts with an assortment of providers, such as occupational therapists, that offer services at reduced rates – known as in-network coverage. If a person visits an out-of-network provider instead, however, their health insurer may require them to pay more; as the out-of-network provider does not have an agreement with the insurance provider and is billing directly.
Many health insurance companies strive to keep their networks small so they can better predict and control costs, yet this isn’t always feasible; an insurer could refuse to add a healthcare provider due to them not meeting certain quality standards or because their cost exceeds an acceptable range. Therefore, it’s crucial that individuals thoroughly research their individual policy to understand how it handles out-of-network providers.
Most Medicare subscribers will have some form of coverage for occupational therapy services through Part B. This typically covers sessions at private practices, hospitals and other facilities – with Medicare typically covering 80 percent once their deductible has been reached.
Medicare Advantage plans typically offer some form of coverage for occupational therapy services as well. However, benefits may only apply when provided through their chosen medical network – making it harder for individuals to locate the services that meet their specific needs from among providers selected by their health insurer.
People enrolled in Medicare Advantage plans should examine their coverage carefully. Medicare Advantage plans tend to restrict themselves to fewer providers and may not cover everything that Original Medicare covers, leading to higher deductibles and coinsurance rates than its Original version would offer. Furthermore, Original Medicare doesn’t always cover therapy services in equal amounts as its equivalent plan does – though most Medigap plans cover Part B coinsurance rate for occupational therapy so beneficiaries can visit an in-network occupational therapist without worrying about having additional out of pocket costs associated with seeing him or her!
