High Co-pay: Specialist co-payment designation for physical therapists
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SPECIALIST CO-PAYMENT DESIGNATION FOR PHYSICAL THERAPISTS

 
Health insurance carriers have designated physical therapists as specialists for purposes of co-payments (the same as cardiologists, neurologists, etc.). Putting physical therapists in the “specialist” category enables health plans to impose on consumers a higher specialist co-payment instead of the lower primary care visit co-payment that plans previously required for physical therapy care.  Physical therapy is routine health care and requires numerous visits.  Under the practice, consumers are essentially forced to self-fund their physical therapy care even though they or their employers are paying thousands of dollars for health insurance. 

An example of the effect of the inequity of this designation is:
 
Pain specialists (anesthesiologist/physiatrist)
Average per visit allowable charge          =        $110.00
Specialist co-payment                              =            40.00
Health Insurer’s responsibility                 =        $  70.00
Patient’s responsibility (%)                      =                 36%
 
Physical Therapist (Outpatient)
Average per visit allowable charge          =        $ 42.00
Specialist co-payment                              =           40.00
Health Insurer’s responsibility                 =        $   2.00
Patient’s responsibility (%)                      =                95%
 
 
A person will probably need to see an anesthesiologist or physiatrist once for a specific condition. On the other hand, it can take a total of 10 physical therapy visits to return the patient to their pre-injury condition. This breaks down to the health insurer having a financial responsibility to the physical therapist of $20 (10 x $2=$20), while the patient would have a financial responsibility of $400 ($10 x $40 = $400). 

High Co-Pay information

Sponsors/Co-sponsors
Senate Bill and memo of support
Assembly Bill and memo of support
Specialist Co-pay Designation for Physical Therapists
Insurance Committee Members
Sample Letter

Workers Comp Information

Sponsors/Co-sponsors
Senate bill and memo of support
WC PTA bill

 

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