Navigating a New Year's Health Insurance
We made it to 2026! For most of us, that means resetting health insurance programs. Often, patients struggle to navigate their health insurance plans in the new year.
A typical health insurance program in 2026 functions as a cost-sharing contract between an individual and an insurer, designed to mitigate the high costs of medical care. The fundamental structure of deductibles, copays, and coinsurance remains the standard for most employer-sponsored and private plans.
Key Insurance Terms Defined
Premium: The fixed monthly fee paid to an insurance provider to keep a health plan active.
Deductible: The specific dollar amount a patient must pay out-of-pocket for covered services each year before the insurance company begins to share costs.
Co-Pay (Copayment): A predetermined, flat fee (e.g., $30 or $60) paid at the time of a medical service, such as a doctor's visit or physical therapy session.
Co-Insurance: The percentage of costs (e.g., 20%) a patient pays for a service after the annual deductible has been met.
Out-of-Pocket Maximum: The most a patient will pay for covered services in a plan year. Once this limit is reached, the insurer pays 100% of the cost for covered, in-network care for the remainder of the year.
Physical Therapy Pay Cycle: How Payments Change
Not helpful yet? This breakdown shows a typical progression of payments for a patient attending physical therapy throughout the year.
1. Meeting the Deductible
Patient Responsibility: Full Cost - Patient pays the full allowable amount for each PT session (often $100–$300)
Insurance Responsibility: $0 - Insurance tracks payments toward the deductible but pays nothing yet
2. After Deductible is Met
Patient Responsibility: Partial Cost - Patient pays only the designated Co-Pay or Co-Insurance (e.g., 20% or $40)
Insurance Responsibility: Majority Cost - Insurance covers the remaining percentage of the bill
3. Out-of-Pocket Max Met
Patient Responsibility: $0 - Patient pays nothing for additional covered PT sessions for the rest of the year
Insurance Responsibility: $100 - Insurance covers the full cost of all in-network, medically necessary PT visits
Tips for Contacting Your Provider
Before starting therapy, call the customer service number on the back of your insurance card or use their online portal to verify your 2026 benefits.
Ask for Outpatient PT Benefits: Specifically ask if "outpatient physical therapy" is a covered benefit under your current 2026 plan.
Verify Requirements: Confirm if you need a referral from a primary care doctor or prior authorization before your first session.
Check for Visit Limits: Some plans limit the number of PT sessions (e.g., 20 visits per year).
Document Everything: Note the date of the call, the name of the representative you spoke with, and a reference number for the conversation.
Wondering if You’re Covered?
Progressive Physical Therapy accepts almost all Insurance Providers including:
Aetna, Auto Claims, Cigna, EBMS, Medicaid, Medicare, Meritain, Moda, Premera, Tricare, VA Health Care, Workers’ Compensation
If you don’t see your health insurance provider listed above, contact our office at (907) 748-0022
this blog post was written by Kevin Glynn, PT, DPT
