Medicare, insurance companies placing caps on rehab visits

Editor’s note: This is the sixth in a series of stories that will explain the 10 essential health benefits required under the Affordable Care Act and explore what effect those requirements will have on patients and caregivers.



A local physical therapist says the Affordable Care Act, also known as Obamacare, isn’t necessarily adding additional rehabilitation benefits to those already covered by health insurance plans.

“Benefits are being cut, not added,” said Phillip Smith, a physical therapist and owner of Sport and Spine Rehab. “Insurance companies and Medicare are now putting caps on how many visits they will pay for.”

Rehabilitation services are one of 10 essential health benefits required for health insurance plans to cover under Obamacare as of Jan. 1, 2014.

Carmen Elliot, senior director of Payment and Practice for the American Physical Therapy Association, said rehabilitation services can include those such as physical therapy, occupational therapy, speech-language pathology and chiropractic medicine.

Even prior to Obamacare, she said, most of these services were covered by insurance.

Smith echoed that statement.

In his 10 years in business, he hasn’t seen any patients without some rehabilitation coverage.

“I can’t speak for it nationally, but everyone we’ve seen between our St. Louis and Central Missouri clinics has had coverage,” he said.

He said he doesn’t see an increased demand for physical therapy.

“As everyone cuts benefits, the demand seems to be weakening,” he said.

He said it can’t be good when people other than the patient and physician are determining how much therapy a patient needs.

“Every patient is different and should be treated accordingly,” he said. “Patients with diabetes or other issues may not heal as fast as others,” he said. “Insurance companies and Medicare still take our money, but we have lost almost all say in who and how much care we can get.”

Elliot does see an increased demand for physical therapy services.

“It can be attributed to the aging American population, particularly baby boomers who are more vulnerable to chronic and debilitating conditions that require physical therapist services,” she said.

Megan Gill, director of strategic communication at the University of Missouri’s School of Health Professions, said physical therapy schools are working to alleviate the demand.

“Every year, we receive more than 250 applications for 44 spots in our (physical therapy) clinical doctorate program,” she said. “This year, we actually filled 60 spots.”

10 essential health benefits

Under the Affordable Care Act, all insurance plans in the Marketplace are required to cover:

· Ambulatory patient services (outpatient care you get without being admitted to a hospital)

· Emergency services

· Hospitalization (such as surgery)

· Maternity and newborn care (care before and after your baby is born)

· Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy)

· Prescription drugs

· Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or chronic conditions to gain or recover mental and physical skills)

· Laboratory services

· Preventive and wellness services and chronic disease management

· Pediatric services

Your questions

The News Tribune received several questions this week about the ACA:

Q: In 2018, a Cadillac Tax of 40 percent will be charged to people with a health insurance plan that costs more than $10,200 for an individual and $27,500 for a family. Is this tax only on the amount over the $10,200 or is it for the total cost of the health insurance plan?

A: The tax is only on the amount over the threshold. According to McGrath Insurance Group, “if a plan exceeds the threshold numbers by $1,000, for example, the insurer or employer would pay a $400 tax.”

Q: How will this tax be collected?

A: According to Coventry Health Care, “the health insurance issuer will be responsible for paying this fee if the plan is fully insured, and self-funded plans will be responsible for paying it themselves. This fee will apply to both grandfathered and non-grandfathered plans.”

Q: Will the threshold increase each year to account for inflation?

A: According to United Healthcare, the thresholds may be increased depending on inflation.

Do you have questions?

We want to answer your questions regarding the ACA; email reporter Olivia Ingle at or call her at 573-761-0248.

Also, feel free to share your experiences with the ACA or your experiences signing up for coverage in the Marketplace


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