Insurance Impact on Healthcare and PT

Insured/Beneficiary

Person covered by the health insurance plan and entitled to receive healthcare beenfits

Provider

Healthcare professional or facility that provides medical services

Premium

Amount you pay regularly to keep your insurance active

Plan coverage

The healthcare services and costs that your insurance will help pay for

In-Network

Providers that have a contract with your insurance company, usually resulting in lower costs

Out-of-Network

Providers without a contract with your insurance company, usually resulting in higher costs

Co-pay

Fixed amount you pay for a healthcare service, such as $20 for a doctor’s visit

Deductible

Amount you must pay out of your own pocket for covered healthcare services before your insurance starts paying

Public health insurance

Health insurance that is provided or funded by the government to help people pay for healthcare services

Examples of public health insurance

Medicare, Medicaid, Department of Defense programs, etc

Medicare benefits…

65 years old or older, people with disability, people requiring care for end-stage renal disease

Medicare

Title 18 of Social Security Act

Workers Compensation

Insurance program that helps pay for medical care and lost wages when an employee is hurt at work

Managed Insurance Plans

Health plan that uses a network of doctors and hospitals to provide care at lower costs

Types of Private Insurance

Aetna, United Health Care, Cigna, etc.

Direct Acesss

Ability to see and receive care from certain healthcare providers without first getting a referral from a primary care physician

Medicare Part A

Hospital insurance → Hospital stays, SNF, hospice care

Medicare Part B

Medical insurance → Doctor visits, outpatient care, preventative services

Medicare Part C

Medicare Advantage Plans offered by private companies that combine parts A and B, often with extra benefits

Medicare Part D

Prescription drug coverage

Workers’ compensation diagnosis code

ICD10

Workers comp requires…

A referral. No Direct Access

Difficulties with Managed Insurance Plans

Need well written documentation for authorization for rehab, need frequent notes, occasionally require peer to peer review

Medicaid

Government-funded health insurance program for people with low income and certain eligible groups like some children, pregnant women, older adults, and people with disabilities

Medicaid is also known as…

Title 19

Private health insurance

Health insurance that is purchases from or provided by a private company rather than the government, can be obtained through and employer

Group Insurance

health insurance provided through an employer for employees and often their families

Self-Insured

Company pays employees’ healthcare costs itself instead of purchasing traditional insurance from an insurance company

High-Deductible Health Plans and Savings Options

Health plans with lower monthly premiums but higher deductibles, often paired with Health Savings Account to help save money for medical expenses

Short-Term COBRA Coverage

Program that allows people to temporarily keep their employer-sponsored health insurance after leaving a job or experiencing certain life events

Health Maintenance Organizations (HMOs)

Managed care plans that require members to use network providers and usually obtain referrals before seeing specialists

Preferred Provider Organizations (PPOs)

Health plan that allows members to see both in-network and out-of-network providers, usually without needed referrals

Supplemental Insurance Plans

Additional insurance that helps pay healthcare costs not covered by Medicare, such as copays, deductibles, and coinsurance

No Insurance

No health coverage, charged as an outpatient, large co-pays and out of pocket costs, don’t qualify for rehab

PT payment in hospitals

Bi-weekly, set amount (doesn’t matter how many people are seen)

PT payment in Home Care Clinic (Full-time)

Salary

PT payment in Home Care Clinic (Independent contracting)

Payment only for a visit

Outpatient Clinics

Salary pay, but can utilize independent contracting