Physical Therapy and Other Forms of Reimbursement

Private and Commercial Insurance

In the United States, there are several thousand health insurance carriers.  The number of plans that these carriers offer is easily 4 times as many.  Commercial  insurers, Blue Cross and Blue Shield Plans and Health Maintenance Organizations, make up the bulk of the Private and Commercial Insurance Carriers.

Commercial Carriers offer health insurance coverage to individuals and groups.  Typically, payment for medical services are made to the beneficiary or to the provider if they have accepted assignment.  These payments are usually made on the basis of an indemnity schedule or a schedule of benefits for specific services.

Blue Cross and Blue Shield plans have evolved over the years.  Blue Cross cover hospital services.  Blue Shield plans typically cover professional services. There are currently 39 Blue Cross and Blue Shield companies in the US.  Blue Cross and Blue Shield plans also provide administrative services for government programs.

Health Maintenance Organizations (HMOs) are plans or programs where health care services are provided to enrolled groups of patients.  These plans are prepaid group practice plans.  The patient may have co-payments and deductibles under these types of arrangements.  Typical HMO arrangements include prepaid group practice model, staff model, Independent Practice Association (IPA) and Network HMOs.

Illinois All Kids Program

The Illinois Department of Healthcare and Family Services operate the All Kids program.  This state program offers Illinois’ uninsured children comprehensive health care that includes doctor’s visits, hospital stays, prescription drugs, vision care, dental care and medical devices.

Illinois School Based Health Services

The Illinois Department of Healthcare and Family Services  and the Illinois State Board of Education have an interagency agreement which allows them to capture federal matching dollars for School-Based Health Services (SBHS). This covers both the direct services provided by Local Education Agencies (LEAs) and for the administrative costs associated with administering Title XIX and Title XXI (State Children's Health Insurance Program) services.

The Individuals with Disabilities Education Act (IDEA), formerly the Education of the Handicapped Act) and Article 14 of the Illinois School Code mandate a free, appropriate public education for all children ages 3 to 21 with disabilities.

Illinois claims federal dollars for certain therapy services provided to children enrolled in special education programs, and for administrative activities.

LEAs are required to provide, at no cost to parents, special education and related services as outlined in an Individualized Education Program (IEP).

IDEA, as clarified by the Amendments of 1986, (P.L.99-457), includes provisions for other agencies to pay for services.

The Omnibus Budget Reconciliation Act of 1989 (OBRA) allows LEAs to enroll as Medicaid providers and to claim reimbursement for certain health services provided to eligible special education students. LEAs may also perform activities that support administration of the programs