Medical Billing, and Practice Management Systems

Can Insurers Still Cap Physical Therapy Visits?

Published: 2010-07-25 22:59:14
By: MICHELLE ANDREWS | New York Times | April 20, 2010

Q. Currently, my insurance has decided that visits to get physical therapy, even if you have had surgery, are limited to 20. You can appeal to get more covered, but it’s an arduous process at best, and there’s no guarantee that you’ll win. Even if you do, they may decide that you get only five more visits. There is even a cap for visits to treat depression and other mental illnesses. Will my insurance company still be able to limit/cap the number of visits to therapy (physical & otherwise) services? — Vicki, Huntington, W.Va.

A. Yes, it’s likely that your insurer will be able to continue to limit physical therapy and mental health benefits under the new health law. Existing health plans won’t ever have to provide the “essential health benefits” that will be mandatory in the health insurance exchanges and for individual and small group plans starting in 2014.

But even health plans subject to the essential benefits provisions are unlikely to offer unlimited coverage in these areas, said Jennifer Tolbert, associate director of the Kaiser Family Foundation. Although mental health and physical therapy will be required benefits in the essential benefits package, insurers may well limit the number of visits that are allowed. That’s because the law says that the essential health benefits should reflect the benefits of a typical employer plan, she said.

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