Open enrollment is one of the few moments in the year when you actually get to make a decision about your health care instead of just reacting to it.
Naturally, most of us rush through this and make it in about five minutes. We compare the monthly premium, pick the smaller number, and move on.
The trouble is that the premium only tells you what coverage costs when you don’t use it. What about when you do?
Physical therapy is exactly the kind of care where that gap shows up, because PT is almost never a single visit. A typical course of care runs somewhere between eight and 20 sessions.
So you have to take details that probably look small and insignificant on paper and multiply by 20.
What should you pay attention to?
First, Know Your Enrollment Window
The dates depend on where your coverage comes from:
Medicare open enrollment runs October 15 through December 7, with changes taking effect January 1.
Healthcare.gov and state marketplace plans open November 1 and run through January 15 in most states. But to have coverage in place on January 1, you generally need to enroll by December 15. A handful of states run on different dates.
Employer plans usually open for a two- or three-week stretch sometime in the fall. Your HR department sets those dates, and they’re easy to miss, so ask around.
Once your window closes, you’re generally locked in until next year unless you have a qualifying life event. That’s what makes this worth getting right.
Beyond the Premium: The Four Things Worth Checking
- Is there a cap on visits?
Many plans limit how many physical therapy visits they’ll cover in a calendar year. This is often somewhere in the range of 20-30. However, sometimes it can be fewer, and sometimes PT is combined with occupational or speech therapy in a single shared pool.
If you’re managing something ongoing, or recovering from a surgery that needs a long runway, a low cap is the detail most likely to interrupt your care partway through. This one is definitely worth knowing before you’re in the middle of it.
- Copay or coinsurance (and how much)?
A copay is a flat amount per visit. Coinsurance is a percentage of the cost. The difference is easy to skim past… but really hard to ignore later.
Want an example?
A $40 copay across 16 visits is $640. In contrast, a 30% coinsurance on the same course of care is a number you can’t calculate in advance.
Neither is automatically better. But you should know which one you’re signing up for.
- Does PT apply before or after your deductible?
Some plans cover therapy visits at a copay from day one. Others don’t actually start helping you pay for your treatment until you meet your full deductible.
On a high-deductible plan, that can mean paying the full negotiated rate. For every visit. For months.
That’s not necessarily the wrong plan – high-deductible plans often pair with an HSA and can be a genuinely good fit – but it’s a very different experience from a $30 copay, and it’s better to know going in.
- Do you need a referral or prior authorization?
In Texas, you may be able to start physical therapy without first seeing a physician. But your insurance plan can still require a referral or prior authorization before they’ll pay. They’re two separate questions, but people routinely collapse them into one.
Ask specifically: does this plan require a physician referral for PT, and does it require prior authorization? The answer changes how quickly you can actually start.
A Short List to Take into Your Enrollment Decision
If you’re comparing plans over the coming months, these are the questions worth asking:
- How many PT visits are covered per year, and is that pool shared with other therapies?
- Is my cost a copay or coinsurance, and what’s the amount?
- Does PT count toward my deductible, or is it covered before I meet it?
- Is a physician referral required? Is prior authorization required?
- Which local clinics are in-network?
That last one deserves a note. In-network and out-of-network can be a very large difference in what you pay, and network lists change from year to year. In other words, a clinic that was covered last year may not be this year, and plans’ online directories aren’t always current.
The most reliable way to find out? Ask the clinic.
If you’re weighing a plan and want to know how it works with us, call us before you enroll. We’d much rather answer that question in October than hit you with a surprise in February.
One Last Thing Worth Knowing
If you have an HSA or FSA, physical therapy is generally an eligible expense. If you’re deciding how much to set aside for next year and your knee’s been bothering you or you have a surgery on the calendar, that’s worth factoring into the number.
Want Another Set of Eyes Or Ears on Your Plan?
We’re not insurance brokers, and we won’t tell you which plan to pick. That’s a big question, and it depends on your health, your budget, and your family’s needs. Ultimately, it has to be your call.
That being said, we do look at PT benefits all day long, and we’re happy to help you understand what a plan actually means for your care.
That’s just part of what being a community clinic looks like.
Questions on coverage, or about whether PT is the right next step for something you’ve been struggling with? Get in touch with us today.
