I am an in-network provider with Medicare and many Medicare Advantage plans. Otherwise, I am out of network with non-medicare insurance.
If you do not have Medicare or a Medicare Advantage plan, you most likely can still get reimbursement for your Physical Therapy services. Many supports and laws are in place that make it easier for you to access and be reimbursed for medical services that are out of network with your insurer and limit your out-of-pocket costs.
What is Maine’s Right to Shop Law? Maine’s Right to Shop Law requires health insurers to pay for certain services, including physical therapy, provided by out-of-network providers if the service cost is less than the average paid to all in-network providers in the state or the standard the insurer pays its network providers. Your insurer must treat the claim as if it was provided by an in-network provider – which means you pay an in-network co-pay / co-insurance, and the claim payment is applied to your in-network deductible and out-of-pocket max, not a separate out-of-network deductible and out of pocket max. You have the power to shop for the best price and best quality services regardless of whether your provider is in-network or not.
What health plans must follow this law?
- Individual health insurance plans purchased in Maine or on healthcare.gov.
- Employer-sponsored health plans that a Maine insurance company fully insures.
- Maine state employee health plans.
What health plans do not need to follow this law?
- Self-insured health plans that large multi-state employers frequently offer.
- HMO plans
- Out-of-state health plans that are not governed by Maine law.
What is the purpose of this law? The right-to-shop law encourages consumers to shop for lower-cost services and ensures that health plans do not punish consumers for choosing out-of-network services that cost less than in-network services.
How do I use the right-to-shop law?
- Compare our out-of-network charges after applying our cash-payment discount to the estimated average for the PT service codes.
- If our charges are less, contact your health plan to notify them you will be exercising your right to choose to see us as an out-of-network provider to confirm you are eligible.
- Read on to learn more about your right to receive a “Good faith estimate” from providers. Call or email us to find out what our services will cost you.
- If your health plan says you are not eligible, we may need to dig deeper – health plans are not used to consumers using this law yet and may give you erroneous information about your eligibility.
- We will give you a receipt (aka “Superbill”) that you can send to your health plan. You will have to be assertive and demand compliance with the law since this law is new and has not been used much.
What are out-of-network benefits? If a healthcare provider contracts with a specific insurance company, they are “in-network” with that insurer. Other healthcare providers may not contract with insurance companies (for many reasons) and thus provide “out of network” services. Your insurer may provide “out of network” benefits. Generally, this means you pay the service upfront and submit it to your insurance company for reimbursement for some or all of the cost. The amount of reimbursement varies depending on your plan.
How do I check my out-of-network (OON) benefits? Your insurance’s website will usually list out-of-network benefits on their website. Before seeing your OON provider, it’s a good idea to call your insurance company to see if your specific policy has OON benefits and, if so, check if there are any requirements for reimbursement. For example, your insurance may require you to have a referral from your doctor to qualify for reimbursement. Some questions you should ask when you are on the phone:
- How much of my deductible has been met this year?
- What is my out-of-network deductible for outpatient physical therapy?
- What is my out-of-network coinsurance for outpatient physical therapy?
- Do I need a referral from an in-network provider to see someone out-of-network?
- How do I submit claim forms for reimbursement? (Claims are forms sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.
What’s a deductible? What is coinsurance? What is a co-pay?
- Your deductible is the amount of money you need to pay before your insurance reimburses for services. Your insurance may have a separate deductible for “out of network” providers.
- Coinsurance is the percentage of the service fee that you, the consumer, is responsible for paying. Your insurance also may have a maximum “allowed amount,” which caps the amount of money the insurance will cover per session.
- A co-pay is a set dollar amount you, the consumer, are responsible for paying. Your insurance also may have a maximum “allowed amount,” which caps the amount of money the insurance will cover per session.
What is a good faith estimate? You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This estimate includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider and any other provider you choose for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill of at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
- Posabilities, Inc., / Even Keel Therapeutic Movement, will provide upon request a Good Faith Estimate for physical therapy services for clients pursuing out-of-network services, not insured, and / or not using insurance to obtain services.
- For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (207)466-9154.
How do I get reimbursed? Once any prerequisites set by your insurer are met (i.e., getting a referral from your provider if necessary), you pay for your physical therapy appointment at the time of service. I will provide you with a superbill which you can then use to submit for reimbursement. Your reimbursement amount may depend on your deductible, coinsurance, and service cost.
Can I use my HealthCare Savings Account (HSA) or Flexible Spending Account (FSA) to pay for Physical Therapy? Absolutely! Whether or not you submit for reimbursement from your insurer, you can use your HSA or FSA to pay for services.