What You Should Know About EmblemHealth And Physical Therapy

What You Should Know About EmblemHealth And Physical Therapy

April 13, 2022

Most patients who require physical therapy rely upon insurance to help them cover the costs of their treatments. Most insurance plans do include this type of treatment, as long as it is considered necessary for your wellbeing, health, or recovery.

Determining exactly how your insurance will cover your treatment, however, can sometimes be confusing. That is why we have put together this guide to health insurance and physical therapy, with a focus on EmblemHealth, the leading insurance provider for patients in the New York Tristate area.

How much does physical therapy cost in NYC?

The cost of physical therapy varies depending upon factors such as the following:

  • Where you live
  • Which provider you choose
  • Which treatments you receive
  • The details of your insurance coverage

PT can cost as much as $350 per session. However, the national average for a single physical therapy session before insurance coverage applies, is $75, with the average range being $55 – $125 per session.

Prices in New York City reflect these averages, with some providers charging on the higher end, due to the cost of living factors in the city.

However, you can expect to find a reliable, compassionate, and effective physical therapist in New York City that is also affordable, especially if you have health insurance that will help you pay for your physical therapy expenses.

What physical therapy benefits does my health insurance provide?

Health insurance plans almost all provide some type of coverage for physical therapy, but they will differ in the details of this coverage. The most important factor in whether or not your treatment is covered is your insurance company’s guidelines regarding what types of treatment are covered. In general, your insurance company will have to deem treatment to be habilitive, rehabilitative, and/or medically necessary before your benefits will kick in.

Here are some of the other ways in which your health insurance benefits can vary based on the plan you hold:

Maximum coverage amounts

This refers to limits your insurance company places on lifetime PT costs, annual PT costs, and/or incident PT costs. Once you reach the limit, your insurance will no longer cover treatment.

In-network vs. out-of-network providers

Many insurance companies require you to visit a physical therapist who is in-network with your provider in order to access full benefits. Visiting an out-of-network provider could mean that your costs are not covered, or that you are responsible for a greater percentage of the costs.

Deductibles and copays

A deductible refers to the amount of money you need to pay before your insurance benefits take effect. A copay is the amount of money you are responsible for at each visit. These will vary from plan to plan.

Out-of-pocket maximums

The out-of-pocket-maximum is the limit on the amount of money your insurance company requires you to pay every year. Once you meet this amount, your treatment may be covered in full.

Visit limits

Your insurance company may limit the number of PT visits covered in a single year.

Referral requirements

Your insurance company may require you to receive a referral from a medical professional before covering the costs of your physical therapy.

Before seeking physical therapy services, consult with your insurance company to determine the details of your plan and how it will affect your treatment costs.

Do all employers in New York offer insurance that covers physical therapy?

Health insurance plans are usually accessed through either a healthcare exchange or through your place of employment. In both cases, most health insurance plans will cover physical therapy that is considered an essential service (e.g. Habilitive, rehabilitative, and/or medically necessary).

Before the Affordable Care Act, some small businesses offered healthcare plans that excluded physical therapy services, making it difficult for their employees to afford the PT care they needed.

However, under the Obama administration, and the Affordable Care Act, most small group health insurance plans were required to offer health insurance that included a number of essential services, including physical therapy.

Since then, virtually all job-based health insurance plans in New York State provide coverage for essential physical therapy services. There are a few plans, however, that do not provide this type of coverage, so always confirm coverage with your insurance company before pursuing PT.

How do healthcare exchange plans cover physical therapy?

The Affordable Care Act similarly required that healthcare plans available through the marketplace exchange cover essential services, which includes physical therapy when it meets the habilitative, rehabilitative, and/or medically necessary requirements.

As a result, you can expect most plans you obtain through the marketplace exchange to offer some type of coverage for your PT. The details of this coverage can vary, however, so make sure you understand the limits of your particular health insurance coverage.

Do EmblemHealth insurance plans cover physical therapy?

As an ACA-compliant health insurance provider, and as the health insurance provider for more than 3 million residents of the New York Tristate area, EmblemHealth plans do provide insurance coverage for physical therapy that is deemed medically necessary.

The details of your coverage, however, will depend upon the insurance plan you choose. EmblemHealth manages numerous insurance plans, including Medicare, Medicaid, small business, individual, and employee-provided plans.

Each one will have its own physical therapy coverages. Here are some factors that can affect your PT coverage under EmblemHealth:

  • Whether your plan is HMO or PPO
  • Whether your physical therapist is in-network
  • Your plan’s copays and deductibles
  • Annual visit limits
  • Out-of-pocket maximums
  • Whether your plan is Medicare, Medicaid, or some other type of coverage

How does EmblemHealth Medicare cover physical therapy?

Medicare is a federal program that offers free healthcare to individuals who are above 65 years old and to certain other patients. Medicare, including certain Medicare plans you can choose through EmblemHealth, will cover physical therapy that is deemed medically necessary by your doctor. Here is a look at the basic structure of this coverage:

  • Medicare Part A covers PT received in the hospital setting.
  • Medicare Part B covers PT received in an outpatient setting.
  • You will be responsible for 20 percent of the Medicare-approved cost of treatment.
  • You will need to meet any required deductibles you have before coverage kicks in.
  • There are no caps on the costs Medicare will pay for PT.
  • Any PT not ordered by a doctor will not be covered.

Does Medicaid in New York cover physical therapy?

Medicaid is a healthcare program designed for low-income individuals. This program is run at a state level, which means that coverage details will vary depending upon the state where you reside.

The good news is that New York State’s Medicaid program does cover physical therapy, at no cost to you. Here are some relevant details regarding that coverage:

  • Most physical therapy must be ordered by a doctor in order for it to be covered by Medicaid.
  • Certain exemptions to this rule apply, including for patients who receive physical therapy in a hospital setting.
  • There are no visit limits on physical therapy visits per year.

When you enroll in EmblemHealth’s Medicaid Managed Care program, you can receive these benefits along with Medicaid’s other healthcare coverages.

What happens if my insurance does not cover physical therapy?

Despite broad insurance coverage of physical therapy, there may be times that insurance does not cover your physical therapy due to any of the following:

  • Lack of insurance
  • Visit limits met
  • PT not deemed necessary
  • Insurance plan does not include PT

In these cases, you still have options for receiving physical therapy. You can self-pay for your treatment sessions, but if the cost is unmanageable, you can also speak to your physical therapy provider.

Most providers can help you set up a payment plan, help you get the most benefit possible out of just a few visits, or suggest at-home routines and exercises to assist your recovery until you can afford physical therapy. The key is to communicate with your provider in order to establish a PT routine that benefits you within your financial limits.

How do I find an EmblemHealth physical therapist who meets my needs?

If you have an EmblemHealth (formerly known as GHI) insurance plan, all you need to do is find an in-network physical therapist who meets your needs for both your schedule and your recovery.

Finding providers is easy by visiting EmblemHealth online and searching their portal based on your area, your insurance plan, and the specialist you need to see. From there, you can explore their website or give them a call to determine whether they offer the services you need, including the following:

  • Treatment of your condition
  • Preventative physical therapy
  • Morning or evening appointments
  • After hours appointments
  • Customized treatment plans
  • Specific treatment approaches
  • Pilates
  • Conditions treated
  • And more

Physical therapy coverage in the New York area is often more comprehensive than you might realize. Here at In Touch NYC PT, we pride ourselves on accepting a wide variety of health insurances, including EmblemHealth plans. We can also work with you to make treatment more affordable if you are seeking physical therapy without insurance. Reach out today to learn more about the customized, compassionate, and affordable physical therapy we can provide to get you started on the path to health.

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