If you hurt yourself while exercising or playing a sport, many doctors will refer you to a sports medicine specialist. But does your health insurance cover a visit to a sports medicine specialist? Most health insurance policies offer some coverage for sports medicine appointments. But the extent of coverage depends on your policy specifics.
Before you make an appointment, review your health insurance policy. And call your health insurance provider if your policy doesn't make things clear. You usually have to jump through some hoops before they’ll cover a visit to a sports medicine specialist.
You’ll learn all about those hoops in this article. Along with that, you’ll find answers to these questions and more:
- How does health insurance cover sports medicine in general?
- How do specific types of health plans cover sports medicine?
- Does health insurance coverage of sports medicine change if you take part in hazardous or “extreme” sports?
- Does health insurance coverage of sports medicine change if you’re a high-school or college athlete?
- How much does it cost to see a sports medicine specialist?
How Does Health Insurance Cover Sports Medicine in General?
The good news here is that most health insurance covers at least some visits to see a sports medicine doctor.
Not all US health plans cover all those visits, though. And they don’t all cover those visits to the same extent, either.
On top of that, even if your health insurance policy covers one of these specialists, it’ll more than likely make you jump through some hoops (or at least follow certain guidelines) before it’ll cover it.
What kind of hoops, you ask? Here are the most common:
Referrals
No matter what kind of health plan you have, you’ll probably need to see your primary care physician first. Then, they’ll refer you to a sports medicine specialist. Insurance companies usually require referrals before they pay for treatment from a specialist.
This isn’t true of all plan and network types, though. If you have a Preferred Provider Organization (PPO) plan, you should be able to see a sports medicine specialist without a physician’s referral.
If yours is a Health Maintenance Organization (HMO) or Point of Service (POS) plan, though, you may need to get a referral first.
POS plans may not require a referral. But you will have lower out of pocket bills for a visit to a sports medicine specialist with a referral.
And if you have an HMO plan and you choose to see a specialist without first getting the OK of your doctor? Expect to pay the full cost of both the visit and any treatment you receive.
Why do some health plans or networks require referrals in these situations? Because insurers want to make sure your injury requires a specialist’s help.
If your doctor says you need that sort of help, your health insurance will cover it (although perhaps not fully). And if he or she says you don’t need it, you’ll be responsible for all costs to see a specialist.
To learn more about how different plan and network types treat different situations, read our article, “HMO vs. PPO: What Do Those Letters Mean?” Check out this one, too: “Which Type of Health Insurance Plan is Right for You?”
Approvals or Authorizations
Unfortunately, you’re not out of the woods after you get a referral to see a sports medicine doctor.
Many health insurance plans require approvals or authorizations before they’ll cover treatments from your sports medicine specialist.
Your primary care physician has nothing to do with this step, though. Instead, it’s the insurance company providing your health coverage that gives the yay or nay.
Thankfully, you may not have to hash that out with the insurer on your own. The specialist (or their staff) should take care of it for you. They’ll contact your insurance company and get approval for any treatment you might need.
You’ll likely have to get approvals for all levels of care suggested by your sports medicine doctor. In other words, you’ll have to get them for major treatments as well as more minor ones.
On the “minor” side, you’ve got things like diagnostic tests or so-called durable medical equipment. On the “major” side, there’s therapy (such as physical or occupational) and surgical procedures.
If your health plan doesn’t make it clear which sports medicine services or treatments require approval, ask the insurance company.
Out-of-Pocket Costs
Another way health insurance plans differ in how they cover sports medicine has to do with their out-of-pocket charges.
You may have to reach a deductible before your plan pays your sports medicine bill. Or you might have a copayment when you get treatment.
Coinsurance charges could come into play in this kind of situation, too. That’s especially true if the sports medicine doctor recommends further treatment. In such cases, you may have to pay a certain percentage of the treatment’s cost. Your health insurance will cover the rest.
Again, if you aren’t sure what out-of-pocket costs you might need to pay when you visit a sports medicine specialist, contact your health insurer. You’ll want to know this information before you agree to any kind of treatment. Otherwise, you could be on the hook for a lot of money.
On a related note: if you have a health plan with high out-of-pocket costs, consider looking into supplementary coverage. Many insurance companies offer this kind of coverage. So do some amateur sports teams or leagues.
How do Specific Health Plans Cover Sports Medicine Specialists?
Now that you know how health insurance generally covers sports medicine specialists, how about your specific plan?
Here’s what you need to know about that:
Job-based health insurance policies
As is often the case with employer-sponsored health insurance, it’s difficult to say exactly how one of them will or won’t cover sports medicine.
The most important factor here is the kind of plan you have. For example, if your job-based health plan is of the HMO or POS variety, you’ll need to get a referral from your physician if you don’t want to pay for the whole thing yourself.
If your job-based plan is a PPO, though, you should be able to see a sports medicine doctor without a referral.
Don’t take this as gospel, however. Before you schedule an appointment with one of these specialists, review your policy. It should tell you if it covers these kinds of visits. If it doesn’t, call or email your insurance company. Someone there will clarify if you need a referral to see a specialist. They’ll also let you know if treatment recommended by that specialist require approval. And they’ll explain which costs your plan covers and which ones you’ll have to pay out of your own pocket.
Obamacare or “Marketplace” health plans
Affordable Care Act marketplace plans come in many different shapes and sizes.
The most common plan types you’re likely to find on here are HMO, PPO, and POS.
Are the HMO, PPO, and POS plans sold via the ACA the same as the ones you can get from an employer? Basically, yes, they are.
That means your doctor will have to give you a referral if you have an HMO or POS policy and you want to cover your sports medicine. And if you have a PPO policy, you should be able to go to one of these specialists without taking that extra step.
Remember, though, referrals are just one piece of this puzzle. Authorizations and out-of-pocket costs are two more. So do what you can to be clear about all three areas before you make any appointments.
Also, if you have to pay a lot of out-of-pocket costs to see a sports medicine doctor, look into supplemental coverage that will help you with some or even all of them.
Off-marketplace health plans
Off-marketplace policies are ones you buy away from the ACA marketplace, directly from insurance companies.
The Affordable Care Act regulates both kinds of plans. In other words, the information shared in the section above holds true here, too.
The advice above about marketplace health insurance policies applies to off-marketplace ones as well. Which is another way of saying: don’t assume you know how your policy treats this kind of care. Do your homework. Ask questions. Ignore either of those things and you could be hit with a big medical bill.
Medicaid
This is another one of those “good news, bad news” situations, unfortunately.
By most accounts, Medicaid covers visits to sports medicine specialists if your primary care doctor thinks they’re needed.
That’s the good news. What’s the bad news? You may have a hard time finding a sports medicine specialist that accepts Medicaid. And even if you do find one that accepts it, you might have to wait a while before you can get in to see him or her.
In fact, two recent studies (read one here and the other here) from the Orthopedic Journal of Sports Medicine found that Americans who rely on Medicaid are more likely than those who have private health insurance to be denied appointments with sports medicine doctors. They also found that Medicaid enrollees usually have to deal with longer waits to see these specialists. If they find one who accepts coverage, that is.
Some specialists who don’t accept Medicaid will help you find one who does, so ask for assistance if you need it.
Medicare
How Medicare treats sports medicine isn’t much different from how the other forms of health insurance discussed in this article treat it.
Medicare should cover your appointment to see one of these specialists if your physician thinks it’s medically necessary. The same is true of any additional treatment or care your sports medicine doctor may prescribe after that initial visit.
There are sure to be many exceptions to this “rule,” though, so talk with a Medicare representative if you’re not clear how your plan covers sports medicine.
Does Health Insurance Cover of Sports Medicine for Hazardous or “Extreme” Sports?
How your health plan covers (or doesn’t cover) sports medicine should be the same whether you’re a golfer or you’re a skydiver.
And that’s true across the board when it comes to hazardous or “extreme” sports. So, your health coverage won’t differentiate between you being into skiing or snowboarding or rock climbing or hang gliding.
If your health insurance policy covers a sports medicine specialist after you’re injured while playing tennis, it should do the same if you’re injured while mountaineering.
The only time that may not be the case: when you travel. Specifically, if you travel outside the US, your current health plan may not cover injuries you sustain while taking part in various sports. And it also may not cover any overseas specialists you seek out for help with those injuries.
For that, you’ll need travel medical insurance. Or at least that’s what you’ll need if you have job-based health insurance or a marketplace or even off-marketplace plan. To learn more about travel medical insurance, read our article: “Does Health Insurance Cover Your Medical Care When You Travel Abroad?”
If you’re on Medicare, you’ll need either a Medicare Advantage plan or Medicare Supplement coverage if you want this kind of protection while traveling abroad. For more information on this topic, check out our article: “Do Medicare, Medicare Advantage, or Medigap Plans Pay For Medical Treatments in Foreign Countries?”
By the way, if you take part in a sport or activity that’s considered hazardous, you’ll want to see this article, too: “Life Insurance for People Who Enjoy Extreme Sports.”
Does Health Insurance Coverage of Sports Medicine Change if You’re a Student Athlete?
Being a high-school or college athlete can impact how your or your parents’ health insurance plan covers sports medicine specialists.
If you have a child who plays soccer for their high school, for example, the school district’s insurance plan may cover any injuries that occur while playing, according to insurancethoughtleadership.com.
Don’t assume that’s how things work at your child’s school, however. It isn’t unusual for a school district’s insurance to only pay out in this way if a student has inadequate or no health coverage. If the school’s plan is better than yours, the school plan will cover treatment of the injury.
The same usually is true of college athletes. Some colleges provide student athletes with health insurance that covers them if they need to need to see sports medicine specialists. Other colleges don’t offer this coverage, though.
This is another of those situations where you don’t want to assume you know how things work. If your child is on a high-school or college sports team, contact your health insurer. Ask if your plan covers injuries that occur on the practice field or during competition. And contact your child’s school, too. Its insurance may override or supplement your own coverage in certain situations.
How Much Does It Cost to See a Sports Medicine Specialist?
The short answer to this question: if you have health insurance and it covers sports medicine specialists, you won’t have to pay much.
That’s about as specific as you can get in an article like this, sadly.
Why? US health plans are all over the map in terms of how they cover these visits. One policy may only charge you a small copayment to see a sports medicine specialist. Or it might make you pay a small amount of coinsurance. Another policy may tie far higher out-of-pocket costs to this kind of care.
Things are a lot less hazy if you don’t have insurance, or if you have a high deductible.
In either of those situations, expect to spend a lot of money to see and receive treatment from a sports medicine doctor. Your initial visit shouldn’t cost too much, even if you don’t have health insurance. At most, you might have to pay a couple of hundred dollars for this.
If that initial visit leads to additional treatment, though, watch out. According to figures the US Department of Health and Human Services released a few years ago, even treating a simple ankle sprain can cost $2,290 without insurance. Something like a broken arm can cost a whole lot more--like $7,700.
And if your injury leads to surgery? Let’s just say $7,700 could be a drop in the bucket compared to what you may have to pay in this sort of situation.
In Conclusion
That really puts into perspective how important health insurance can be when it comes to sports medicine, doesn’t it?
With the right health plan, seeing one of these specialists is no big deal. With the wrong plan, or with no plan at all, though, it can be the exact opposite.
The key takeaway here: if you have health insurance, learn as much as possible about it before you make an appointment with a sports medicine doctor. Know which costs your plan will pay for and which ones you’ll need to cover well in advance of your first visit.
Do that and you and your loved ones can rest assured you’ll be taken care of no matter which kind of sports injury you suffer. And you can also rest assured you won’t be surprised by an eye-opening medical bill.
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