It’s common for patients to run up against limits on treatments that are capped in number by their health plan. Often, this occurs for treatments like physical therapy, chiropractic and speech therapy. But there are actions you can take to ensure you get the necessary care.
The best thing to do is ask questions early and often about how much care you can get and what it is going to cost you, both before and after you’ve hit your limits, said Shawn Stack, a policy director at the Healthcare Financial Management Association.
“Physical therapy is one of the more common services that employers or insurance plans limit for consumers,” Stack said. “Many insurances and some Medicaid and Medicare Advantage plans cap physical therapy visits at usually around 20 visits per year.”
Even though these types of limits are usually written into the summary of benefits of coverage or the full plan document that an insurer or benefits provider offers, those documents are not always easy to decipher. That’s why you would want to find out your limits early in the process, obtaining the information from the provider or the insurance company, before you start care and potentially could be racking up a lot of costs.
As a result, Stack recommends you ask the following questions:
- How many visits per year are covered for the specific medical procedure, item or service?
- Does my deductible or co-pay apply to each visit?
- What happens if I need more visits than the plan covers?
- Can my provider request an exception if the service or the item is medically necessary?
- Is prior authorization required before I start the treatment?
- Are there in-network versus out-of-network differences in those limits for that specific service?
In addition, it’s possible to ask for an extension of coverage if the initial round of treatments isn’t enough. If that’s denied by the health plan, patients can appeal that decision. In addition, it may be possible to adjust the treatment schedule with the provider or to ask whether there’s a cash-pay discount for treatments that aren’t covered, Stack said.
