Understanding Your Insurance

Medicare Part B

Medicare Part B has a $198 deductible for the 2020 calendar year, which must be paid before therapy services are covered. After your deductible has been met, Medicare covers 80% of your therapy services. Medicare also has a cap of $2080 for the 2020 calendar year toward your physical therapy and speech language therapy services combined. It will pay up to an additional $2080 for Occupational Therapy which is a separate benefit. Since Medicare pays for 80% of the allowed $2080, that means $416 is not covered by Medicare. If you have a secondary insurance, the coinsurance may cover part or all of this cost. Please visit www.medicare.gov for more information.

Medicare Advantage

Some people who think they “have Medicare” as their primary carrier, actually have a Medicare Advantage or Medicare Part C plan. This means that the services are covered by an independent insurance company, contracted by Medicare. We must be in-network with that carrier in order for our services to be covered. The therapy benefits usually require prior authorization, which we will obtain. The Medicare Advantage plans usually carry a copay for all therapy visits. The copays vary, depending on your particular plan, and we make every effort to verify your copay prior to the start of services. However, we encourage you to contact your insurance carrier for questions about your benefits and patient responsibilities.

Private Carriers

We accept assignment for most major plans and will contact your carrier prior to the start of services to verify your therapy benefits. The coverage widely varies between plans.

Medicaid

Most people with Medicaid now have “managed” Medicaid plans. These plans require pre-authorization from a case manager, which we will obtain for you. The benefits may vary depending on which plan you have. Some people may still have traditional Medicaid plans, which may cover up to 20 visits per benefit year, or a “waiver”, which may cover more than 20 visits per year. We will obtain any necessary authorizations.

We verify all insurance benefits prior to starting services. In most cases, we make every attempt to bill your insurance directly for services. You will also be notified if there is a copay for services prior to starting. The explanations above do not in any way guarantee payment. It is important that you understand your insurance benefits. Please contact your carriers directly for specific questions regarding your benefits. These explanations are for general guidance only and coverage is determined only by your insurance carrier, and is subject to change at any time.