Direct access:  

There is some form of direct access for physical therapy (PT) in all 50 states. What that means is you may come to a physical therapist without seeing an MD first. Occasionally insurance companies require a prescription to cover services, so it is always good to check first. 

Co-Pay:

A predetermined fee that an individual pays for health care services, for example, $30 per visit.

Co-Insurance:

A predetermined percentage that an individual pays for health care services, for example, 20% per visit.

Deductible:

The deductible is the amount an individual must pay for health care expenses before their insurance benefits kick in.  For example, if you have a $1000 deductible, you must pay that before your insurance begins to reimburse.

Out of Pocket Maximum:

A predetermined maximum amount of money that an individual must pay out of pocket before an insurance company will pay 100 percent for an individual’s health care expenses. Sometimes this is the same as your deductible, others it may be in addition to your deductible. 

CAP:

A cap is either a maximum amount of money an insurance company will spend on services or a set number of visits a patient is allowed for services per year. Plans that have caps are referred to as "capitated plans" and typically are through a group plan. 

Explanation of Benefits:

An explanation of benefits is the insurance company’s written explanation regarding a claim, showing what they paid and what the client will likely pay. You can think of it as an estimate, not a bill. 

In Network:

In-network refers to providers that are part of a health plan’s preferred provider organization (PPO) which has negotiated a discount. Insured individuals usually pay less when using an in-network provider.

Out Of Network:

This phrase refers to providers who are considered nonparticipants in an insurance plan. Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-network health professionals may not be covered, or covered only in part by an individual’s insurance company.

Health Savings Account (HSA):

A savings account created for individuals who are covered under high-deductible health plans (HDHPs) to save for medical expenses. The contributions are invested over time and can be used to pay for qualified medical expenses, which include physical therapy.

Provider:

Provider is a term used for health care professionals who provide health care services such as physicians, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.

Reasonable and Customary Fees: 

The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure.


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