HEALTHCARE NAVIGATOR
Please utilize our custom ABC’s of healthcare navigator to find valuable information about key terms in the health industry.

A

Accountable Care Organization

  • Accountable care organizations are a group of doctors, hospitals, and providers who come together voluntarily to give quality care to Medicare patients. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.
  • What does it mean for physical therapy? PT clinics are currently not included in ACOs but the American Physical Therapy Association (APTA) has recommended the inclusions of PTs in ACOs.

Advanced Premium Tax Credit

  • The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through the Marketplace.
  • What does it mean for physical therapy? The tax credit provides assistance for you to afford your healthcare coverage. If you know you need PT and have a tax credit, make sure your plan covers PT.

Allowed Amount

  • The maximum dollar amount an insurance company will pay for a given procedure or service.
  • What does it mean for physical therapy? Allowed amount depends on coverage. Contact your insurance provider or get in touch with us and we can look into it for you.

Accreditation

  • A process where a professional association or nongovernmental service grants recognition to a health care institution for demonstrated ability to meet predetermined criteria for established standards.
  • What does it mean for physical therapy? The Commission on Accreditation in Physical Therapy Education (CAPTE) accredits programs to assure quality. The state of Washington has three accredited schools: the University of Washington, Eastern Washington University, and the University of Puget Sound.

Actuarial Value

  • The average share of total health spending on essential benefits paid for by a health plan.
  • What does this mean for physical therapy? The value is categorized in “metal levels” where bronze has the least generous cost coverage and platinum has the most generous cost coverage.

Affordable Care Act

  • Refers to two legislative acts that has expanded Medicaid coverage and has made many changes to health care coverage throughout the industry. The ACA was enacted with the goals of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage, and reducing the costs of healthcare for individuals and the government. It introduced a number of mechanisms — including mandates, subsidies, and insurance exchanges — meant to increase coverage and affordability.
  • What does this mean for physical therapy? The ACA has expanded health coverage, has forced changes in the way PT is offered, and made changes in payment options. The bottom line, is, PT isn’t going anywhere and we’re here and available for anyone.

Agent

  • A person who you choose in advance to make health care decisions for you if you are unable to do so yourself.
  • What does this mean for physical therapy? Make sure you communicate your needs clearly to your chosen agent as they will be in charge of your health decisions if you are unable.

Annual Limit

  • A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health plan.
  • What does this mean for physical therapy? There are annual limits to PT and it can depend on your plan. Consult your healthcare provider for a better understanding of your annual limit.
B

Balance Billing

  • When a provider bills you for the difference between the provider’s charge and the allowed amount.
  • What does this mean for physical therapy? A common practice throughout the healthcare industry. At Pro-Motion, we do our best to communicate what your insurance covers and what you will be responsible for from day one.

Benefits

  • The health care items or services covered under a health insurance plan.
  • What does this mean for physical therapy? PT services are often included in a benefits package but you should always check with your insurance provider.

Broker

  • A person who can help you apply for or enroll in a qualified health plan. They can make specific recommendations and they are licensed and regulated by the state.
  • What does this mean for physical therapy? Brokers recommend benefit plans so make sure to communicate your physical therapy needs up front with them.
C

Care Coordination

  • The organization of your treatment across several health care providers.
  • What does this mean for physical therapy? PT clinics are in constant contact with your doctors and aware of their recommendations before and during your treatment.

Catastrophic Health Plan

  • Catastrophic coverage is an insurance plan designed to protect a patient from financial disaster if a serious medical emergency arises. They are health plans that meet all of the requirements applicable to other Qualified Health Plans but that don’t cover any benefits other than 3 primary care visits per year before the plan’s deductible is met. To qualify, you must be under 30 years of age or qualify for a “hardship exemption.”
  • What does this mean for physical therapy? PT is not covered under the catastrophic health plan.

Centers for Medicare & Medicaid Services (CMS)

  • The federal agency that runs Medicare, Medicaid, and Children’s Health Insurance Programs. What does this mean for physical therapy? Physical therapy is offered through CMS but is dependent on an individual basis. There are typically therapy caps and it would be important to talk to your CMS contact.

Certified Applicant Counselor

  • An individual affiliated with a designated organization that is trained and able to help customers, small businesses, and their employees as they look for health coverage options through the Marketplace.
  • What does this mean for physical therapy? These counselors are a guide meant to help you through a complicated process. Be sure to communicate any physical therapy needs to them.

Children’s Health Insurance Program (CHIP)

  • An insurance program jointly funded by state and federal government that provides health coverage to low-income children.
  • What does this mean for physical therapy? If you have a child enrolled in CHIP, be sure to discuss your physical therapy needs with them in order to get a full understanding of what’s available.

Chronic Disease Management

  • An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education.
  • What does this mean for physical therapy? PT can be a key factor in dealing with chronic pain. Discuss your options with your insurance provider.

Claim

  • A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
  • What does this mean for physical therapy? Having discussed your insurance options at the front-end of service, the back office will provide claims to your insurance company after each date of service has been applied.

Co-Insurance

  • Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service. You pay coinsurance plus any deductibles you owe.
  • What does this mean for physical therapy? Coinsurance is the amount you owe at the end of services provided. 20% is a popular coinsurance figure. So you should expect to pay 20% of the total cost, plus any deductibles owed.

Coordination Benefits

  • A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.
  • What does this mean for physical therapy? From a user-perspective, there’s not much to worry about here.

COBRA

  • A federal law that may allow you to temporarily keep your health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
  • What does this mean for physical therapy? You have the ability to keep your coverage if it includes physical therapy, even after a difficult event for a short period of time.

Community Rating

  • A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.
  • What does this mean for physical therapy? You have the peace of mind that your health insurance plan isn’t unfairly biased against you.

Conversion

  • The ability, in some states, to switch your job-based coverage to an individual policy when you lose eligibility for job-based coverage.
  • What does this mean for physical therapy? Washington State offers conversion plans that will allow you to switch over if you lose group coverage.

Copayment

  • A fixed amount you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health insurance.
  • What does this mean for physical therapy? It depends on your coverage, but you should expect to provide your copay.

Cost Sharing

  • The share of costs covered by your insurance that you pay out of your own pocket such as deductibles, coinsurance, and copayments.
  • What does this mean for physical therapy? Check your plan, but a large majority of plans have cost sharing structures built into them that you should be aware of.

Cost Sharing Reduction

  • A discount that lowers the amount you have to pay out of pocket for deductibles, coinsurance, and copayments.
  • What does this mean for physical therapy? Check with your insurance provider, but you might qualify if your income is below a certain level or other specific instances.

Court Awards

  • Money that’s due to you as a result of a lawsuit.
  • What does this mean for physical therapy? If the lawsuit deals with a personal injury, there might be a portion set aside for health-related expenses.
D

Deductible

  • The amount you owe for health care services your health insurance plan covers before your health insurance plan begins to pay.
  • What does this mean for physical therapy? Your deductible applies to your physical therapy activities. It must be met before your benefits engage.

Dependent Coverage

  • Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
  • What does this mean for physical therapy? Dependents receive the same coverage as the policyholder.

Disability

  • A limit in range of major life activities.
  • What does this mean for physical therapy? PT is acutely capable at working with disability patients.
E

Emergency Medical Condition

  • An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.
  • What does this mean for physical therapy? In emergency situations go to the emergency room to seek treatment. Depending on the condition, physical therapy is an excellent option for rehabilitation.

Emergency Services

  • Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
  • What does this mean for physical therapy? Most emergency services can be found in a hospital. If needed, call 911 to report your emergency if you feel it is life threatening. Again, physical therapy can be an excellent option for rehabilitation, depending on the condition.

Employer Shared Responsibility Payment (ESRP)

  • The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to its full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment called the ESRP.
  • What does this mean for physical therapy? Talk to your employer about your specific insurance plan to get more details about what it covers regarding physical therapy.

Employer or Union Retiree Plans

  • Plans that provide health and/or drug coverage to former employees or members, and, in some cases, their families.
  • What does this mean for physical therapy? It depends on the plan. Be sure to discuss your physical therapy needs with your insurance provider.

Essential Health Benefits

  • Must include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventative and wellness services and chronic disease management; and pediatric services, including oral and vision care.
  • What does this mean for physical therapy? Physical therapy meets the definition of essential due to its rehabilitative services as well as its wellness services.

Exclusions

  • Health care services that your health insurance plan doesn’t pay for or cover.
  • What does this mean for physical therapy? Physical therapy isn’t covered in every single plan. Be sure to talk with your insurance provider to better understand your plan.

Exclusive Provider Organization (EPO) Plan

  • A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network.
  • What does this mean for physical therapy? If the PT clinic is in network, your plan spells out the exact details of your coverage. If it’s not in network, you are still able to get services, but the cost will come out of your pocket, or it might be a higher coinsurance.

External Review

  • A review of a plan’s decision to deny coverage for or payment of a service by an independent third party not related to the plan.
  • What does this mean for physical therapy? If your insurance company has denied a claim, you have the right to appeal. You can do so internally through the insurance company, or you can use an external review.
F

Federal Poverty Level

  • A measure of income level issued annually by the Department of Health and Human Services.
  • What does this mean for physical therapy? Federal poverty levels are used to determine what kind of programs or benefits you are eligible for.

Fee for Service

  • A method in which doctors and other health care providers are paid for each service performed.
  • What does this mean for physical therapy? There are options for those that are uninsured. Talk to us about your needs and we might be able to come to an agreement.

Flexible Benefits Plan

  • A benefit program that offers employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans, and child care. Even if a common core of benefits is required, you might be able to allocate dollars to the kinds of benefits you desire.
  • What does this mean for physical therapy? If you know you need physical therapy, you might be able to allocate more toward that specific benefit. Talk to your insurance provider.

Flexible Spending Account (FSA)

  • An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA.
  • What does this mean for physical therapy? FSAs are ways of avoiding steep out-of-pocket costs when you have a high deductible or coinsurance. Talk to your employer about FSA options.
G

Grandfathered

  • A group health plan that was created — or an individual health insurance policy that was purchased — on or before March 23, 2010. Grandfathered plans are exempt from many changes required under the Affordable Care Act. Grandfathered plans can lose their status if they make too many changes that reduce benefits.
  • What does this mean for physical therapy? You shouldn’t expect any changes to service and cost for the most part.

Group Health Plan

  • A health plan offered by an employer or an employee organization that provides health coverage to employees and their families.
  • What does this mean for physical therapy? It depends on the plan. It is your responsibility to communicate your health needs to your employer or employee organization to make sure you have optimal coverage.

Guaranteed Issue

  • A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services.
  • What does this mean for physical therapy? It allows you to have confidence that you can get the services you need at an equal cost.

Guaranteed Renewal

  • A requirement that your health insurance issuer most offer to renew your policy as long as you continue to pay your premiums.
  • What does this mean for physical therapy? You have the confidence that you can continue treatment without losing your coverage at any given moment.
H

Habilative/Habilitation Services

  • Health care services that help you keep, learn, or improve your skills and functioning for daily living.
  • What does this mean for physical therapy? PT is all about function and a high quality of life. It is a defining example of habilitation services.

Health Coverage

  • Legal entitlement to payment or reimbursement for your health care costs, generally under contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, or Medicaid.
  • What does this mean for physical therapy? Your health coverage gives you access to physical therapy services.

Health Insurance

  • A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
  • What does this mean for physical therapy? Health insurance covers a portion of the costs involved with physical therapy services.

Health Maintenance Organization (HMO)

  • A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
  • What does this mean for physical therapy? You need to use a clinic that’s in network to ensure you gain the benefits of being a part of an HMO.

Health Plan Categories

  • Plans in the Marketplace are primarily separated into 4 health plan categories — Bronze, Silver, Gold, or Platinum — based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This isn’t the same as coinsurance, in which you pay a specific percentage of the cost of a specific service.
  • What does this mean for physical therapy? Your category will provide different benefits for physical therapy services. Consult your insurance provider.

Health Reimbursement Account (HRA)

  • Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.
  • What does this mean for physical therapy? HRA might be used for physical therapy services. It depends on what qualifies. Consult with your employer.

Health Savings Account (HSA)

  • A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.
  • What does this mean for physical therapy? A method to help you deal with high deductibles which can be helpful when using physical therapy services.

High Deductible Health Plan

  • A plan that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
  • What does this mean for physical therapy? High deductibles can make physical therapy costly. If used in conjunction with a health savings account, it can be more manageable.
I

In Person Assistance Personnel Program

  • Individual or organizations that are trained and able to provide help to consumers, small businesses, and their employees as they look for health coverage options, including helping them complete eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.
  • What does this mean for physical therapy? Make sure to communicate your needs with people in these programs so you can make the best possible choice for your healthcare

Individual Health Insurance Policy

  • Policies for people that aren’t connected to job-based coverage. Individual health insurance policies are regulated under state law.
  • What does this mean for physical therapy? You are in charge of your individual health insurance policy. Be sure to communicate your needs to your insurance provider as you are the final decision maker for what you want and what you can afford.
J

Job-Based Health Plan

  • Coverage that is offered to an employee (and often his or her family) by an employer.
  • What does this mean for physical therapy? It’s important to be in communication with your employer about your benefits to make sure you are well-acquainted with your coverage.
L

Large Group Health Plan

  • In general, a group health plan that covers employees of an employer that has 101 or more employees.
  • What does this mean for physical therapy? Much like a job-based health plan, a large group health plan depends in the type. Be in communication with your employers about your health needs.

Lifetime Limit

  • A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.
  • What does this mean for physical therapy? Certain plans with lifetime limits will affect physical therapy. Make sure you know the limits to your plan and make your decisions based on whether or not you think you may go over the limit.
M

Medicaid

  • A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults.
  • What does this mean for physical therapy? Generally, physical therapy is considered an optional benefit under Medicaid. In Washington State, physical therapy is an essential health benefit provided under Apple Health.

Medical Loss Ratio (MLR)

  • A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees.
  • What does this mean for physical therapy? The MLR is a good ratio to use to understand the effectiveness of your insurance as it measures the amount of money the insurer uses from your premium to pay for services such as physical therapy.

Medically Necessary

  • Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
  • What does this mean for physical therapy? Per APTA standards, PT is medically necessary as determined by the licensed physical therapist based on the results of a physical therapy evaluation. It is considered medically necessary if the type, amount, and duration of services outlined in the plan of care increases the likelihood of meeting one or more of these stated goals: to improve function, minimize loss of function, or decrease risk of injury or disease.

Medicare

  • A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities.
  • What does this mean for physical therapy? Certain medicare plans help pay for part of physical therapy but includes therapy cap limits. Consult your provider for specifics.

Medicare Advantage (Medicare Part C)

  • A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
  • What does this mean for physical therapy? Same as medicare.

Minimum Essential Coverage

  • The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
  • What does this mean for physical therapy? Physical therapy is categorized as an essential health benefit, but the amount of coverage varies depending on the type of plan.

Minimum Value

  • A health plan meets this standard if it’s designed to pay at least 60% of the total cost of medical services for a standard population.
  • What does this mean for physical therapy? While it varies from plan to plan, you should expect to see at least 60% of your health care services, physical therapy included, get covered by your insurance plan.

Multi-Employer Plan

  • In general, a group health plan that’s sponsored jointly by 2 or more employers.
  • What does this mean for physical therapy? The same applies from a group health plan. It’s important to be in communication with your employer about your benefits to make sure you are well-acquainted with your coverage.
N

Network

  • The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
  • What does this mean for physical therapy? It is important for you to check with your insurance provider to see if your desired physical therapy clinic is located within your network.

New Plan

  • A health plan that is not a grandfathered health plan and therefore subject to all of the reforms in the Affordable Care Act.
  • What does this mean for physical therapy? Much has changed and much will continue to change with ACA, but in general, you can expect expansions in coverage, innovative care programs, and changes in payment.

Non-Preferred Provider

  • A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider.
  • What does this mean for physical therapy? Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Nondiscrimination

  • A requirement that job-based coverage not discriminate based on health status. Coverage under job-based plans cannot be denied or restricted. You also can’t be charged more because of your health status. Job-based plans can restrict coverage based on other factors such as part-time employment that aren’t related to health status.
  • What does this mean for physical therapy? You can feel confident that you will receive the best quality of care no matter your health status.
O

Open Enrollment Period

  • The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace.
  • What does this mean for physical therapy? Enrollment typically occurs in the winter. Be sure to do your homework and get your insurance plan organized if you expect physical therapy needs in the near future.

Out-of-Network Coinsurance

  • The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don’t contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
  • What does this mean for physical therapy? Be sure to check with your insurance provider to confirm in- and out-of-network providers so you can get a better sense of cost.

Out-of-Network Copayment

  • A fixed amount (for example, $30) you pay for covered health care services from providers who don’t contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
  • What does this mean for physical therapy? Be sure to check with your insurance provider to confirm in- and out-of-network providers so you can get a better sense of cost.

Out-of-Pocket Costs

  • Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.
  • What does this mean for physical therapy? Out-of-pocket costs can come as a shock if you haven’t been following the details of your insurance coverage closely. Pro-Motion will walk you through what they estimate your out-of-pocket costs will be, but it is also just an estimate. If you ever have a question about out-of-pocket costs, contact your insurance provider.

Out-of-Pocket Estimate

  • An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.
  • What does this mean for physical therapy? Pro-Motion runs these estimates for you to help you understand and budget for your PT needs.

Out-of-Pocket Maximum/Limit

  • The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits.
  • What does this mean for physical therapy? Pro-Motion will communicate your maximum if it applies to your services. If you are curious about your limit, contact your insurance provider for specific information.
P

Physician Services

  • Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
  • What does this mean for physical therapy? Physical therapist works closely with doctors to ensure rehabilitative services are optimally performed.

Plan

  • A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
  • What does this mean for physical therapy? As an essential health benefit, physical therapy will be covered in most plans. Discuss with your insurance provider for specific details.

Plan Year

  • A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year.
  • What does this mean for physical therapy? To find out when your plan year begins, you can check your plan documents or ask your employer.

Point-of-Service Plan (POS)

  • A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
  • What does this mean for physical therapy? It depends on the details of the specific plan and the referral from the primary care doctor. Remember, you are in control of your health. You can discuss your needs with your insurance provider and primary care doctor.

Policy Year

  • A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year.
  • What does this mean for physical therapy? To find out when your plan year begins, you can check your plan documents or ask your insurer.

Pre-Existing Condition

  • A health problem you had before the date that new health coverage starts.
  • What does this mean for physical therapy? Things are still in flux, but the ACA aims to ensure no discrimination from insurance providers based on pre-existing conditions.

Preauthorization

  • A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.
  • What does this mean for physical therapy? Preauthorization varies by policy or plan. Discuss the details with your insurance provider.

Preferred Provider

  • A provider who has a contract with your health insurer or plan to provide services to you at a discount.
  • What does this mean for physical therapy? Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Premium

  • The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
  • What does this mean for physical therapy? To keep your benefits, you must remain current with your premiums.

Prevention

  • Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.
  • What does this mean for physical therapy? PT can be a critical part of prevention, function, and a high quality of life.

Preventative Services

  • Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
  • What does this mean for physical therapy? Your ability to optimize function can lead to better health.

Primary Care

  • Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.
  • What does this mean for physical therapy? Your physical therapist coordinates care with your physician when a need for PT services arises.

Primary Care Physician

  • A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
  • What does this mean for physical therapy? Your physical therapist coordinates care with your physician when a need for PT services arises.

Primary Care Provider

  • A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
  • What does this mean for physical therapy? Your physical therapist coordinates care with your physician when a need for PT services arises.

Public Health

  • A field that seeks to improve lives and the health of communities through the prevention and treatment of disease and the promotion of healthy behaviors such as healthy eating and exercise.
  • What does this mean for physical therapy? PT is a big component of promoting healthy behaviors such as health eating and exercise in the community.
Q

Qualified Health Plan

  • Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.
  • What does this mean for physical therapy? You can have assurance that your qualified health plan will cover physical therapy services under the provision of essential health benefits. To get specific details, you will need to chat with your insurance provider.
R

Reconstructive Surgery

  • Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
  • What does this mean for physical therapy? PT is a critical part of the rehabilitative process after such surgeries occur.

Referral

  • A written recommendation from your primary care doctor for you to see a specialist or get certain medical services.
  • What does this mean for physical therapy? A referral from your primary care doctor is a recommendation for further care outside of the primary care doctor’s expertise. Of note, a referral is not an order to go to that specific specialist. You are free to choose the specialist in the referred field that makes you most comfortable.

Rehabilitative/Rehabilitation Services

  • Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled.
  • What does this mean for physical therapy? PT is a rehabilitative service that helps you improve function and your quality of life.

Rider (Exclusionary Rider)

  • A rider is an amendment to an insurance policy. Some riders will add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to your policy).
  • What does this mean for physical therapy? It depends on your insurance policy. You can discuss amendments pertaining to physical therapy with them.
S

Self-Insured Plan

  • Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.
  • What does this mean for physical therapy? Your employer is in charge of your plan. You will need to communicate your physical therapy needs to your employer.

Service Area

  • A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services.
  • What does this mean for physical therapy? It’s something to consider if you are moving as the plan may disenroll you if you move out of the plan’s service area. Be sure to check with your insurance provider before you move!

Special Health Care Need

  • The health care and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally.
  • What does this mean for physical therapy? PT can be a helpful service for certain special health care needs such as scoliosis.

Specialist

  • A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
  • What does this mean for physical therapy? PT is considered a specialist field.

State Continuation Coverage

  • A state-based requirement similar to COBRA that applies to group health insurance policies of employers with fewer than 20 employees. In some states, state continuation coverage rules also apply to larger group insurance policies and add to COBRA protections. For example, in some states, if you’re leaving a job-based plan, you must be allowed to continue your coverage until you reach the age of Medicare eligibility.
  • You have the ability to keep your coverage if it includes physical therapy, even after a difficult event for a short period of time.

State Health Insurance Assistance Program (SHIP)

  • A state program that gets funding from the federal government to provide free local health coverage counseling to people with Medicare.
  • What does this mean for physical therapy? Check with Washington Apple Health to see what and how it’s applied.

Subsidized Coverage

  • Health coverage that’s obtained through financial assistance from programs to help people with low and middle incomes.
  • What does this mean for physical therapy? Subsidized coverage works the same as normal coverage. Contact your provider and work with a broker to see if you qualify for subsidized coverage.

Summary of Benefits and Coverage

  • An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans.
  • What does this mean for physical therapy? Many plans on the marketplace can be easily compared and contrasted to best fit your needs.
T

TRICARE

  • A health care program for active-duty and retired uniformed services members and their families.
  • What does this mean for physical therapy? PT is covered through essential benefits but the specific details will need to be outlined from your insurance provider.

Total Cost Estimate (for health coverage)

  • The total amount you may have to pay for health plan coverage, which is estimated before you actually have the coverage and have health expenses under the coverage.
  • What does this mean for physical therapy? Your total cost estimate will give you a basic idea of your premiums, deductibles, coinsurance/copayments.
U

UCR (Usual, Customary, and Reasonable)

  • The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
  • What does this mean for physical therapy? It gives you peace of mind that you aren’t getting overcharged for services.

Uncompensated Care

  • Health care or services provided by hospitals or health care providers that don’t get reimbursed. Often uncompensated care arises when people don’t have insurance and cannot afford to pay the cost of care.
  • What does this mean for physical therapy? Uncompensated care is usually avoided by giving out-of-pocket estimates before service begins.
V

Value-Based Purchasing (VBP)

  • Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.
  • What does this mean for physical therapy? Your insurance provider will work with your physical therapist to confirm the number of visits required for optimal care.
W

Waiting Period (Job-Based Coverage)

  • The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.
  • What does this mean for physical therapy? Be sure to communicate your needs to your employer and understand the timeline of your waiting period so that your services needed are covered.

Wellness Programs

  • A program intended to improve and promote health and fitness that’s usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.
  • What does this mean for physical therapy? PT can be a critical component of a wellness program due to its increase in function and quality of life. Discuss your needs with your employer or insurance provider.

Worker’s Compensation

  • An insurance plan that employers are required to have to cover employees who get sick or injured on the job.
  • What does this mean for physical therapy? PT helps in the rehabilitative process. Check with your employer to see what’s covered and what costs are involved