As the new year approaches, it is a good time to review your health insurance plan and how it covers therapy for your kiddo! There are a few key terms to look at when you’ve selected your plan for the upcoming calendar year. These terms can help you figure out what works best for you and your family.

Copay: A fixed amount that you will pay for a covered health care service. A copay does not usually apply toward a plan’s deductible, but there are exceptions. If your plan has a copay for therapy visits, then this is what you will be paying each time your kiddo comes for a visit with us.

Deductible: This is the amount you must pay toward medical services before your plan will begin covering any of the costs of therapy. If your plan does not list a copay amount for therapy services, then you will likely be paying toward your deductible. The amount of the deductible depends on the plan you choose during open enrollment. For instance, if you pick a plan with a $1000 deductible, then you will be paying the full cost of therapy until you have reached $1000. Then your plan will begin paying a set percentage of the cost. It is good to note that any other medical services you may need will likely also be going toward your deductible to help you reach that set amount quicker. 

If you are paying toward a deductible, the cost of visits can vary each week. The cost will depend on what the therapist has worked on with your kiddo in each session. Different activities and strategies require different billing codes which vary in cost. This is why we are only able to give a broad estimate of cost for deductible payments.

Coinsurance: Once your deductible has been met, the amount you pay will switch to a coinsurance. For example, if your plan pays 80% of the cost after the deductible is met, then you would be responsible for the remaining 20%.

Out-of-pocket Maximum: This is a set amount that you would pay for covered medical expenses each year before your plan begins to pay in full for those services.

Visit Limit: Most plans have a set number of visits that they allow for therapy each plan year. And it is important to read the details and not just to see the numbers that are listed! Some plans may allow for 30 visits EACH of OT, ST, and PT. But other plans may allow for only 30 visits TOTAL to be used between all three therapies. Some plans may allow for additional visits, but many plans will not. If your kiddo has used all of their visits in a plan year, then it is possible that your insurance will not cover any more visits after that set number has been used. If that is the case, then you would begin paying our private pay rates in order to continue therapy. It is also important to note that your visit limit does not start over if your kiddo had been getting services elsewhere before coming to WPT.

Authorization: Many plans require approval before your insurance will cover therapy. We will gladly obtain this authorization for you when your kiddo starts their therapy journey at WPT! If you switch insurance plans for any reason throughout the year, then it is vital that you let us know. If your new plan requires authorization, but we didn’t know ahead of time, then you would be financially responsible for any services that are not covered by your insurance. We do not receive any alerts from insurance companies when a member has dropped or picked up a new plan. We rely on you to let us know so we can make sure your child’s new insurance will cover therapy visits.

Hopefully, these brief definitions give you a better idea of what is going on in your insurance plan. We will always do our best to answer any questions about your coverage, but it is ultimately up to the plan members to know what their plan covers. We encourage you to reach out to the member number on the back of your ID card with any questions you may have prior to your child’s first therapy visit.