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Get the Most out of your Health Insurance Plan!

By: Dr. Ashley Bertorelli, PT, DPT


How to get the MOST out of your Health Insurance Plan!


It’s that time of year that most people are thinking all about and planning for the upcoming holidays, and perhaps even plans and goals for the New Year. But us in the healthcare and medical world who deal with insurance companies on a daily basis are also thinking about other things- upcoming deductible resets, therapy visits renewing, ends to OOP Max, expiring FSA’s, and more! Yes, boring, but if you have health insurance, you should be thinking about these things too! In this article, I want to explain a little more about what these things are, why they matter, and most importantly…. how to get the most out of your health insurance plan at the end of the year, and going into the new year! In less than 5 minutes, get ready to be SUPER informed and ready to make the most of your hard-earned health insurance! Here we GO…..



These days, most people are paying hundreds of dollars per month on health insurance, even when their employer is contributing. It’s not unheard of for a family of four to be paying around $2000/month for health insurance! That’s why it’s more important than EVER to know what you’re getting, and how to make the most out of your particular health insurance plan.


First, here are some very important definitions, and what you should know (If you don’t know your particular health insurance plan details, call the number on the back of your health insurance card and ask to speak with a representative to find out. Or, most insurance plans offer online portals in which you can log into and find out the specifics about your plan).


  1. Deductible. Definition: The amount you pay for covered health care services before your insurance plan starts to pay. With a $4,000 deductible, for example, you pay the first $4,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance.

  2. Out-of-pocket max (a.k.a. OOP Max). Definition: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and/or coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

  3. Visit limits: Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. It is not unusual for some insurances to cover 20 visits of PT per year, whereas another may have a 120-visit limit, or even unlimited visits per year.

  4. Prior authorizations: Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

  5. Flex Spending Account (FSA): Is a special account you put money into that you use to pay for certain out-of-pocket health care costs. You don't pay taxes on this money. This means you'll save an amount equal to the taxes you would have paid on the money you set aside.

  6. Coinsurance vs. copay: A copay is a set rate you pay for prescriptions, doctor visits, and other types of care. Coinsurance is the percentage of costs you pay after you've met your deductible. For most patients, the “specialist copay” is what they pay for (usually listed on the front of your health insurance card). So, if your specialist copay is $30, that’s what you pay for each PT visit, assuming your deductible is met. If you have a 20% coinsurance and your health insurance plan has a contracted rate to cover $60 per PT visit, you’ll pay 20% of $60, or $12 per visit.


Okay, the boring definitions are over. Now let’s find out how to get the MOST out of your health insurance plan, plus some special considerations and hacks for some of our local health insurance plans (think: CPDHP, Empire Plan/MPN, and others!). Knowing and using these insurance hacks aren’t fraudulent or wrong, they’re just smart, assuming you could use the care and especially if you’ve been holding out on visiting a medical professional for financial reasons.


Hack #1: Most deductibles reset on January 1st. But check with your particular health insurance plan, as some start July 1st, and others at other times of the year. If you’ve met your deductible and it’s about to reset on January 1st, now’s the time to get treatment you’ve been holding out on, but haven’t had the time for. Think: Orthopedic Physical Therapy, Pelvic Floor Physical Therapy, Physical Therapy for headaches, balance, or vertigo… okay yes, we do offer all of these 😉 … Acupuncture (yes, some insurances cover this now!), Chiropractic care, massage therapy (check with your insurance plan, this is also covered sometimes!).


Hack #2: Check with your insurance provider to see if you’ve met or if you’re close to meeting your Out-of-pocket max. Once that happens, all your medical care is covered 100%, no cost to you whatsoever. Yes, including Physical Therapy 😊


Hack #3: Know your Visit limits, and exactly when they reset. We have several patients with a 20 visit/year max for PT, and have already used up those visits in 2023. For most of these patients, their visits will reset back to 0 on January 1st, 2024, meaning they can schedule their evaluations now for the first week or two of January in order to get back into care assuming it’s not urgent and they can wait until January (as always, we do offer self-pay PT if ever needed and if your visits have maxed out already).


Hack #4: Use up your FSA before it expires!!! Research has shown that more than $400 million a year is forfeited in FSA funds. Wow. Many FSA’s expire on December 31st, so use that money now! Our clinic offers Custom foot orthotics and other wellness and fitness equipment (theraband, resistance band loops, foam rollers, lumbar car and chair supports, etc.) that would qualify for FSA spending.


**And here are some “good to know” items for some local health insurance plans:**


CDPHP Medicare Replacement Plan: You get unlimited Physical Therapy visits. You just owe your copay or coinsurance. There are no visit caps, and no prior authorization or MD script needed to get started.


CDPHP Plans: Check to see if your plan offers “Life Points.” If you qualify, you can get reimbursed a certain amount for gym memberships, your kids’ rec and travel sports registration fees, fitness watches (Fitbit, Apple watch), and more! You can also earn points and dollars toward Amazon gift cards for going to your Annual Physical, getting a flu shot, and for exercising. Pretty cool! These also expire at the end of the year, so submit your information NOW!


Empire Plan/MPN/NYS Health insurance plan: You may qualify for 1 pair of custom foot orthotics from our clinic at NO COST! This is a $300+ value, so don’t let that slide! If you don’t love in-shoe orthotics, you can get custom orthotic flip flops, pretty sweet B-) Also with MPN, you do need authorization for PT visits after your Initial evaluation, which our clinic submits for and files the paperwork as a complementary service to you.


Okay, that’s enough insurance talk for me. Now, let me get back to treating my patients 😉 Send your health insurance, Physical Therapy, and other questions to: ashleyb@thegrpt.com or to get started or re-established as a patient with our clinic, request an evaluation or consultation here: https://www.thegrpt.com/events-and-offers


In good health,


Dr. Ashley Bertorelli, PT, DPT, Founder/Owner of The Green Room PT



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