Each insurance enrollment season many of my patients look to consider changing insurance plans or companies. There are a few variables here that are generally not part of the patient-available program summaries which are important to know to make sure you’re getting the coverage you want and need. Normally I handle insurance benefit checks on behalf of my patients, but I have zero access to this information until your insurance plan is active, so you’ll have to take the questions below to your insurance broker, HR rep, or whoever else is your insurance plan contact.
We will mostly address this from the perspective of massage and physical therapy benefits, and while we will also cover some more generalized topics, I also encourage you to speak with your other providers to get any specific information you need from them to make sure you have the coverage you need for their services as well.
With that, let's look at the questions I would make sure to ask to confirm that our care is covered for you, and we’ll go into more detail after that summary. If you do not ask these questions and get answers as asked below, expect for there to be an important gap in coverage.
Coverage Questions:
NOTE: If I’m out of network with your insurance, make sure to check these all specifically for an out of network provider.
What is your deductible and out of pocket max?
What is the copay or coinsurance for massage and physical therapy, and is it before or after the deductible?
Do I need a preauthorization, referral or prescription for massage or physical therapy?
Is there an annual benefit maximum (in number of visits or total costs) for massage or physical therapy?
Is there a maximum number of units (this is session duration) per date of service or per procedure for massage or physical therapy, and specifically for the procedure codes 97110, 97112, 97140, 97026 and 97124?
Are there any exclusions, limitations, or other requirements for the above procedure codes?
Also: Make sure to keep track of whatever documentation you get on this from your rep, not just for your own reference, but to hold them to it if someone misquotes plan benefits and so on.
The Insurance Companies:
I am currently in network with: Providence, Blue Cross, Aetna, and Kaiser (for massage only, physical therapy services will be out of network). Other common local companies include Cigna, Pacific Source and Moda. I cannot offer any up to date information on working with these companies out of network.
Providence generally has good coverage with a high number of covered sessions a year and no duration limits, though some plans have preauthorizations. Patient cost a session varies significantly, from $5-80 depending on plan.
Blue Cross (Regence, the Oregon BC anyway) is capped at one hour of service, and does occasionally require preauthorizations, but tend to have a decent amount of annual coverage. Patient costs vary in my experience typically from $30-40/session.
Aetna tends to have no preauthorization or similar requirements, and a high maximum of sessions a year, but are capped at an hour per date of service. Patient costs tend to be $20-25/session.
Kaiser, for in-network massage, does not generally have any preauthorization needs, but usually only covers 12 one hour sessions a year. Typically copays of $25/session. Kaiser is highly limiting for our work.
Insurance Basics and Details:
Okay, let's get into a bit more of the meanings of some of the above terms.
Your Premium: This is the most straightforward one, the monthly cost for your insurance plan. Naturally the higher you pay up front, the lower costs SHOULD be to use your benefits.
Deductible: For many of your benefits, you will have to pay for your medical costs equal to your deductible before the insurance will pay for anything that is subject to a deductible. This is usually at least for imaging, blood tests, hospital/urgent care visits, and so on, but can be many professional services as well. You’ll want to know what services require your deductible to be paid first before coverage kicks in. More on that below.
You will want to know what your individual deductible is and family if applicable, which is a shared deductible across all family members in your insurance. If that family deductible is met, everyone's deductible is considered met. I’ve seen deductibles range from $100 to 10,000 (usually for out of network on the latter, but it really varies). If we are out of network with your insurance, you’ll want to know if it is an out of network specific deductible, as sometimes they are not shared between in and out of network services.
Copay / Coinsurance: Even after the deductible is met, you’ll still have a portion of the costs to pay, which will vary by service. Typically copays are a $5-40 per service fee which usually don’t require the deductible to be met first. A coinsurance is a percentage of the cost you will have to pay, commonly anywhere from 5-40%, and usually requires your deductible to be met first. You will not have both a copay and coinsurance, just one of the two.
In either case you will need to know if a given service (like massage or physical therapy) has a copay or coinsurance, how much, if they are before or after your deductible. It often changes between in and out of network services.
Out of Pocket Maximum: This doesn’t apply to most people in any given year, but at least ostensibly if you pay enough for your medical care to have paid more than your out of pocket maximum, your insurance is supposed to cover all covered medical costs for the rest of the year.
Pre/Prior-Authorizations, Referrals, Prescriptions: We do not need any of these to render care, but your insurance may require one of them to cover it. I have not seen more than one of these required at once for a given service, but there’s always an exception somewhere. If it’s in-network, the provider is responsible for getting any preauthorization. Out of network, you’ll be responsible for attaining it, and the process depends on the insurance plan. Referrals (uncommon but they pop up) or prescriptions (rare), will need to come from your doctor so you would have to acquire one.
You’ll want to ask if massage or physical therapy (often but not always treated differently from each other) will require a preauthorization, prescription, or referral for care. Make sure to specify in or out of network. These are not necessarily obstacles to care initially, but preauthorizations especially can be obstructive to ongoing care coverage if the case is more complicated.
Annual Session and Date of Service Duration Maximums: Some insurance companies are very limiting in how many sessions they cover a year, or how long sessions can be, which can overall have a very big impact on care. Aetna, Regence Blue Cross (Oregon plans), and Kaiser rarely cover more than an hour per date of service, for example, which isn’t by itself a big deal, even if it can be inefficient. Kaiser, however, typically only covers 12 sessions a year. For some cases this is plenty, but for others it is not near enough, depending on the complexity of the medical situation in front of us.
In either case, you’ll want to know if your plan is going to cover what you need, be it from us, or other service types. These I specifically like to have reviewed based on the specific service ‘procedure code’ (CPT code).
“I want to check for any exclusions, requirements, or limitations for specific CPT codes, including maximum dates of service per year, and maximum number of units per date of service.”
We would check the following CPT codes for our services: (97124, 97026, 97110, 97112, 97140). We can generally get by with our care as long as some of these are covered, but let us know if some of them are not so we can discuss if this will in fact cover our services adequately.
Also note: Some insurance companies as part of their sales pitch say that they have some kind of discount program where providers may offer you discounted services. This is not a real thing. It is on the assumption that providers will give you a cheaper ‘cash rate’ than insurance rates, but this is often not true and we providers have nothing to do with it to start with, so this can be ignored entirely.
This should overall give you the information you need to confirm your insurance will cover our services and the general costs and limitations. If you have more questions, please get in touch and I will help where I can.