A common question we receive is “Will my physical therapy be covered?” The answer is not always simple, because it depends on different factors such as your age, the nature of the complaint, whether you have had surgery, whether or not you need a referral and your insurance package.
So because it is not always easy to know whether your physical therapy is covered, we have tried to list everything as clearly as possible. We would like to add that it is always your own responsibility to know how you are insured. So always double check with your insurance company. But of course we are happy to lend a hand!
Article content
- When is physical therapy covered or not covered
- Children and adolescents up to 18 years of age
- Chronic indications
- Physical therapy after surgery
- COPD and rheumatoid arthritis
- Osteoarthritis of the hip/knee
- Physiotherapy at home
- Why a contract with health insurance is important
- Practical Tips: What can you do yourself?
- Questions about your compensation?
When is physical therapy covered or not covered
Physical therapy is not standard in the basic insurance for adults. That means that for many complaints, you pay for them yourself or need supplemental insurance. But there are exceptions
- Not compensated under the basic insurance: For ‘normal’ complaints, such as a pulled muscle, back or neck pain or a sports injury, the reimbursement depends on the number of treatments in your supplementary insurance. Don’t have supplementary insurance or have you run out of reimbursement? Then you pay for the treatments yourself.
No referral is needed for these complaints and you can make an appointment with the physiotherapist directly. - Is reimbursed from the basic insurance: For children under 18 years and for specific, long-term conditions with a chronic indication, the treatments are directly reimbursed by the basic insurance.
Some chronic conditions or after certain operations such as a knee or hip prosthesis or a hernia operation is from the 21st
Children and adolescents without a chronic indication do not need a referral to make an appointment with the physiotherapist. Chronic conditions do require a referral.
Reimbursement physiotherapy children and adolescents up to 18 years of age
Children and adolescents under 18 are reimbursed for 9 treatments per complaint per year. Are more treatments needed? Then insurance may reimburse another 9 treatments. It depends on the health insurance and the policy whether they do so. So always check carefully with your insurance company.
Need additional treatments after that? These then come from the parents’ supplementary insurance or must be paid for by yourself.
If the child has a chronic indication, all treatments are covered.
There is no deductible for children and adolescents under the age of 18.
Chronic indication
Some conditions are on the so-called Chronic list (also called list Borst). Examples of chronic indications are:
- A stroke (CVA)
- COPD (at certain severity)
- MS
- Rheumatoid arthritis
- Osteoarthritis of the hip/knee
- Rehabilitation after surgery on e.g. a joint
The chronic indication determines in which claim code it falls and whether your treatments are (partially) reimbursed from the basic insurance and also for how long. It may seem a bit cryptic now, but later it will become clear why we name these codes.
Common claim codes for chronic indications are:
- 008 : the first 20 treatments for a chronic indication, such as MS, CVA or after orthopedic surgery. These treatments are reimbursed from the supplementary insurance and/or are self-paid.
For example, if you get 9 treatments reimbursed from your supplementary insurance, you pay the remaining 11 treatments yourself. - 001: from the 21st treatment (after the 20 treatments in code 008) unlimited number of treatments are reimbursed from the basic insurance. The health insurance company determines on the basis of the chronic indication how long this code is valid.
- 012 : 12 treatments per 12 months are reimbursed from the basic insurance. Other treatments within that year go from the supplementary insurance or are at your own expense.
- 022 : From the first treatment, these are reimbursed under the basic insurance. This entitlement code has no fixed end date or limited duration.
Please note that these treatments reimbursed by basic insurance are then covered by the annual deductible.
View the list of all chronic conditions here.
Physical therapy after surgery
Sometimes physical therapy can provide good support during rehabilitation after surgery. Especially with orthopedic surgery, it is sometimes even crucial to rehabilitate through physical therapy to ensure a full recovery. With knee surgery such as cruciate ligament surgery or knee replacement, it is desirable to start physical therapy as early as 2-3 days after surgery. After hip surgery, it is between 2 and 5 days.
Reimbursement
The first 20 treatments fall under claim code 008.
These treatments are reimbursed from your supplementary insurance and/or are at your own expense.
From the 21st treatment onwards, the treatments fall under code 001.
These treatments are reimbursed from the basic insurance.
Excess
As long as you have not yet used up your excess, it will be used from the 21st treatment.
Referral
A referral is required to be within this code. Often after surgery, the chronic indication is valid for one year from the date of the referral.
COPD and in rheumatoid arthritis
COPD from GOLD stage 2 and up (some health insurances require that the treated physiotherapist is in the Chronic Care Network to be reimbursed, this is NOT the case with us. Therefore, an additional check is important) and rheumatoid arthritis with severe functional limitations fall under chronic code 022 due to medical necessity.
Reimbursement
These treatments are reimbursed directly from the1st treatment by the basic insurance and there is no limited number of treatments.
Deductible
However, the annual deductible is used here if you haven’t already passed it.
Referral
Yes, a referral is required to use this entitlement code.
For less severe COPD and rheumatoid arthritis, no referral is needed for physical therapy. In that case, treatments are declared in code 009 and are paid for out of supplementary insurance or self-pay.
Ask your own doctor for advice if you are unsure if you have a chronic indication with this complaint, this doctor can also give the referral right away.
Osteoarthritis of the hip/knee
Reimbursement
You will be reimbursed for 12 treatments per 12 months from the basic insurance, per side. If you have more than 12 treatments in that year, you come under code 009 and pay for them yourself or from the supplementary insurance.
If the indication is determined again after one year, you will come back into code 012 and again be reimbursed for 12 treatments in 12 months.
Deductible
The treatments paid for from the basic insurance are subject to the deductible.
At Salland and at VGZ (from 2026) there is a deductible.
Referral
This varies by insurance company. Some health insurance companies require a referral while others do not.
What applies to you can be checked with your health insurance company.
Physiotherapy at home
Sometimes it is not possible to come to the practice for physical therapy. For example, after hip surgery or surgery for a knee replacement. In that case, we also offer physical therapy at home.
This does require a referral from the general practitioner or medical specialist. Otherwise, these treatments will not be covered by insurance.
Why a contract with health insurance is important
If you want to be sure that all treatments covered by the supplementary insurance and/or basic insurance will be fully reimbursed. Is it important that the practice has a contract with your health insurance company.
Refund policy
If the physical therapist has no contract, you will first have to pay the bill yourself to the practice. Then you can submit it to your health insurance, only then the reimbursement is usually not 100%. This is called a restitution policy.
Difference in cost between private amount and health insurance amount
Sometimes we get the question why the cost of a treatment is different when it is reimbursed by the insurance as when the treatment has to be paid by yourself. A very understandable question of course and we are happy to explain.
When a physical therapy practice enters into a contract with an insurance company, the health insurance company determines the amount they pay per treatment. Therefore, that amount can also vary by insurance company.
In addition, there are practice rates. These are market-based rates for a physical therapy practice that are applied to private bills. Thus, these are different rates than insurance rates.
Some physical therapy practices deliberately do not have a contract with certain health insurers. This is usually due to low reimbursements and additional requirements from the insurer, making it difficult to continue to provide good care at a fair price.
We have deliberately chosen not to distinguish between health insurance companies. Thus, we work with all companies and physiotherapy from your supplementary insurance or from the basic insurance will be reimbursed as long as you are entitled to it according to your policy.
It does mean that once the supplementary reimbursement runs out, there is a difference between the amount the health insurance pays for treatment and our practice fee, which you have to pay yourself when your treatments are no longer reimbursed by the health insurance.
This is normal practice in physical therapy: the amount of reimbursement and the number of reimbursed treatments are always determined by the health insurance company and the policy conditions, not by us as a practice.
Practical Tips: What can you do yourself?
- Check your health insurance before you start.
Pay special attention:
- How many treatments will you be reimbursed for?
- Does it apply from basic insurance, supplemental insurance or both?
- Do you have to use up your deductible first?
- Ask if the practice is contracted with your health insurance company.
(Work With Care contracts with every health insurance company) - Keep track of the number of treatments or your term of your chronic indication yourself.
That way you won’t be surprised when your health insurance reimbursement runs out. - Unsure if you have a chronic indication? Consult with your specialist doctor, family doctor or physical therapist.
Questions about your compensation?
Please feel free to contact us! We are happy to help you clarify your situation and what your insurance will cover.
