FAIR Health Consumer Access

Coverage for Physical and Occupational Therapy

Sometimes an illness, injury or disorder can leave you needing physical and/or occupational therapy. Either type of therapy may be recommended by your doctor to improve your health and well-being. Health insurance varies in how much and how often it covers physical and occupational therapy. This article will give you an overview of physical and occupational therapy. It will also tell you the kinds of commercial and government coverage available, as well as other ways to manage the costs of physical and occupational therapy.

Physical and Occupational Therapy Overview
Physical therapy (PT) is treatment you get to improve your movement. It can also reduce or manage pain, restore function and prevent disability. PT can help with a lot of different health issues. Some examples are sports injuries; broken or sprained limbs; and age-related health problems, like arthritis. PT often includes exercises that improve strength or range of motion; hands-on therapies, like manipulating soft tissue; and heat and cold therapy. It can also include hydrotherapy (exercise in a pool), ultrasound and balance training, among others.

Occupational therapy (OT) helps you do things that are part of your daily life. Examples include household tasks, hobbies, school and work. OT can help with any injury. It can also help with a disability or a health problem you have that makes it hard to do things you would normally do, like getting dressed. Some health problems that may leave you needing OT include stroke, traumatic brain injury or loss of a limb. An occupational therapist can also suggest ways to make your home easier to live in.

Sometimes an illness, injury or disorder will leave you needing equipment to help you do things. Such durable medical equipment (DME) includes wheelchairs, scooters, canes and walkers. It can also include prosthetics, orthotics and other supplies. OT can sometimes help you use DME, such as a wheelchair or a prosthetic limb.

Commercial Coverage
Most commercial health insurance you get through your work or a family member’s work will cover PT and OT if they’re recommended by your healthcare provider and provided by a licensed physical or occupational therapist. You’ll need to check how many visits and the visit durations that are covered per year with your insurance carrier and compare it with the number of PT or OT sessions that you need. If you need PT or OT several times a week, for example, those visits can add up quickly and, if so, may exceed your insurer’s limits. Sometimes you’ll have to meet your deductible (a fixed dollar amount your plan sets) before your insurance starts to pay. Check with your plan, and also check if you’ll need to pay a copay or coinsurance. These are the amounts you may have to pay under your plan’s in-network cost-sharing provisions. If your healthcare provider prescribes a number of visits that exceeds what your insurance covers, discuss with your healthcare provider and make a plan.

Workers’ compensation (WC). WC is a type of insurance your employer gets. It covers medical expenses and lost earnings if you get injured or become sick while doing your job. It can cover PT and OT if needed. Almost all state governments require employers to have WC. In Texas, employers have the choice to offer WC coverage. Some state WC programs require a referral from your doctor. Check out WC state resources for PT here.

Auto insurance and personal injury protection (PIP). Auto insurance companies may cover PT and OT if needed after a car accident. In most states, if you’re hurt in an accident, the auto insurance of the driver at fault should cover your medical costs. In states with no-fault policies, PIP insurance will cover the medical bills instead. Contact your state’s insurance department to find out what coverage is available where you are.

Wherever you decide to get your PT or OT, remember to check that it’s covered and how many visits per year are covered. Be aware that your plan year may be different from the calendar year. Be sure to check that the provider is in network with your insurance before you start treatment. And get a referral if needed. Also, check to see if your insurance covers DME, and if so, what kinds.

Government Coverage
Medicare is public health insurance for people over age 65 or with certain disabilities. It will help pay for PT and OT if a healthcare provider says you need it. But your provider might recommend care that isn’t covered by Medicare. Or they might recommend you get PT or OT more often than Medicare covers. Find out more about Medicare and PT here, and about Medicare and OT here. If you need DME, Medicare may cover that too, if your doctor prescribes it. Find out about Medicare-covered DME here.

Medicaid and Children’s Health Insurance Program (CHIP) are public health insurance programs for people with low income. Both are managed by individual states. PT and OT are listed as optional benefits. This means that states don’t have to cover them under Medicaid and CHIP. But many do. Contact your state’s agency to find out how to apply. The agency can also tell you whether and how much PT and OT it will cover.

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). If you need PT and/or OT because of a disability, you could qualify for SSDI. SSDI gives you monthly payments if you have a disability that stops you from working for a year or more. You can use these payments to help pay for PT or OT. You generally must have worked for at least 5 out of the last 10 years to get SSDI. And after two years on this benefit, you automatically get Medicare. If your income is low, you might also be able to get SSI, which is additional monthly payments. Find out more here.

Department of Veterans Affairs (VA) and TRICARE. If you’re a veteran or a service member, the VA can help cover PT and OT. The VA also covers DME, such as prosthetic and sensory aid services, if you need them. These services include any device that supports or replaces a body part or function. Check out the Veterans Health Library for rehabilitation information and exercises.

If you’re an active-duty service member, TRICARE also covers PT and OT. Both therapies are covered when provided by a licensed provider. There are some PT and OT services that TRICARE won’t cover. These include exercises not related to restoring a specific lack of function, and others. Find out what TRICARE covers for PT here and for OT here.

Other Ways to Manage the Costs of PT and OT
Flexible spending account (FSA) or health savings account (HSA). You can often use money in your FSA or HSA to pay for PT or OT. Ask your employer about setting up an account if you don’t have one. Money that goes into an FSA or HSA is pretax. So, it can be a good way to save on healthcare expenses. To use your FSA or HSA for PT or OT, you may need a letter of medical necessity from your healthcare provider.

Discounts and payment plans. If you’re paying out of pocket, ask your physical or occupational therapist if they can give you a discount. Some practitioners will offer a sliding scale based on your income. If that’s not an option, ask for a payment plan.

FH^® Medical Cost Lookup Tool. Check out our medical cost lookup tool to find out what PT or OT typically costs in your area. You can compare these cost estimates with what your out-of-network provider charges. If your provider charges more, use the estimates to negotiate a better price.

Charitable organizations. Check out some charitable organizations online to see if they offer free or low-cost PT or OT services. If you need PT or OT due to a specific medical condition, such as a stroke, an organization like The Stroke Foundation could help. For example, it offers a stroke survivor fund that can cover the cost of PT and OT.

Universities and specialty training centers. Sometimes universities or training centers will offer free or low-cost PT and OT services. Be sure to check out some in your area.

Free online resources. Some practitioners post free content, often for children, such as activities for handwriting, sensory processing and self-care, on their websites. Ask your physical or occupational therapist if there are any free online activities that could help you or your child.

Resources
ChoosePT is a site run by the nonprofit American Physical Therapy Association that explains the benefits of PT. You can also use the site to find a physical therapist near you.

American Occupational Therapy Association is a nonprofit that has resources to help you find out about OT. Find out what health conditions OT can benefit here.

Now I Can is a nonprofit foundation dedicated to helping children with disabilities. It offers therapy grants to help families pay for intensive and traditional PT for their children.

The Movement Network is a nonprofit that provides free PT for underserved communities in the United States.