June 8, 2024

Does Medicare Cover Physical Therapy? Full Guide

Health care providers may recommend services more often than what Medicare covers, or services that are not covered by Medicare at all. Patients may need to pay out of pocket for services that are not covered by Medicare. It is important for patients to ask questions and understand why their doctor is recommending certain services and what portion, if any, Medicare will pay for them.

Medicare Coverage for Physical Therapy

Medicare Part B can cover the cost of physical therapy sessions, helping individuals regain movement and reduce pain and discomfort. However, individuals usually need to pay a deductible and copayment for Medicare-covered physical therapy services. While Medicare does not have a spending limit on physical therapy sessions, a person's healthcare provider must indicate that their care is medically necessary once the cost reaches $2,110. A definitive treatment plan must also be in place for Medicare to continue coverage.

Crop anonymous male therapist massaging back of man during treatment procedure in wellness studio

Physical Therapy with Original Medicare

Medicare pays for physical therapy under Part B for outpatient services, Part A for inpatient services in hospitals or skilled nursing facilities, and also at home under certain conditions. Individuals must meet their Part B deductible before Medicare funds outpatient physical therapy, with a 20% coinsurance requirement for the Medicare-approved amount.

Physical Therapy with Medicare Advantage

Medicare Advantage plans cover physical therapy in line with Parts A and B but may require individuals to use services from providers in an agreed network. Additionally, a physical therapist and physician must continually evaluate the effectiveness and medical necessity of physical therapy sessions. Medicare requires re-certification of medical necessity after the total costs exceed $2,110. When physical therapy services exceed $3,000, Medicare may require a targeted medical review to ensure appropriate billing and continued medical necessity.

Consider an example scenario: A person with Medicare who was in a car accident underwent physical therapy to improve strength and mobility, exceeding $2,110 in costs. Their therapist and possibly doctor agreed to continue therapy, with recertification for medical necessity.

Types of Therapy Covered by Medicare

Medicare Parts A and B cover physical therapy, occupational therapy, and speech-language pathology that is medically necessary for treating injuries, illnesses, chronic conditions, and aiding recovery from various health issues. Medicare Part B covers outpatient physical therapy, occupational therapy, and speech-language pathology if certified as needed by a doctor or provider. Coverage begins after the annual Part B deductible is met and includes 20% of the Medicare-approved amount for services received at a doctor's office, hospital outpatient department, outpatient rehabilitation facility, or skilled nursing facility.

Two 2 Kg. Blue Hex Dumbbells on White Surface

Creating and Reviewing Care Plans

For outpatient services, a care plan must be created and regularly reviewed by a doctor or therapist to ensure continued coverage under Medicare Part B. In 2018, the therapy cap for outpatient therapy under Original Medicare was removed, meaning there are no longer limits on how much therapy Medicare will cover annually. Medicare covers outpatient therapy at 80% of the Medicare-approved amount, with the patient responsible for a 20% coinsurance after meeting the Part B deductible.

Once total therapy costs reach a certain amount ($2,330 for PT/SLP and OT in 2024), the provider must confirm that the therapy is medically necessary. Medicare pays for up to $1,864 (80% of the $2,330 limit) before requiring the provider to confirm medical necessity. Outpatient therapy can be received at various locations, including therapists' offices, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Skilled Nursing Facilities (SNFs), and at home through home health agencies.

Therapy Type Coverage Medicare Documentation
Physical Therapy Covered under Part B for outpatient services, Part A for inpatient services, and at home under certain conditions. Annual deductible required. 20% coinsurance on Medicare-approved amount. Recertification for medical necessity if costs exceed $2,110.
Occupational Therapy Covered under Medicare Part B for outpatient services Annual deductible required. 20% coinsurance on Medicare-approved amount. Continued coverage requires confirmation of medical necessity once costs reach $2,330 (adjusts annually).
Speech-Language Pathology Covered under Medicare Part B for outpatient services Annual deductible required. 20% coinsurance on Medicare-approved amount. Continued coverage requires confirmation of medical necessity once costs reach $2,330 (adjusts annually).

Medicare's coverage rules for outpatient therapy do not apply if therapy is received as part of a Medicare-covered SNF stay or home health care. Patients have the right to appeal Medicare's denial of coverage if care is deemed not medically necessary.

Understanding Medicare Parts and Medical Necessity

Medicare covers three main types of outpatient rehabilitation therapy: physical therapy, occupational therapy, and speech-language pathology services. Medicare Part B pays 80% of the Medicare-approved amount for outpatient therapy services, with the patient being responsible for the remaining 20% after meeting the Part B deductible.

Costs and Coverage for Medicare Advantage Plans

Costs for Medicare rehab coverage with a Medicare Advantage plan (Part C) vary depending on the specific plan the individual has. Medicare Advantage plans are offered by private insurance companies and must provide coverage at least as good as Original Medicare (Parts A & B).

Appealing Medicare Denials

Individuals can appeal a denial of Medicare coverage for physical therapy. This process involves reviewing the denial notice, gathering supporting documentation, contacting Medicare, submitting a written appeal, following the appeals process, and seeking assistance if needed.

Frequently Asked Questions (FAQ)

How many sessions of PT does Medicare cover?

Medicare Part B can cover the cost of physical therapy sessions as long as the therapy is considered medically necessary by a healthcare provider. While there is no annual limit on the number of sessions, when therapy costs reach $2,110, the care must be reviewed to ensure continued medical necessity. This ensures that the therapy remains eligible for coverage under Medicare.

How much does Medicare pay for physical therapy per visit?

Medicare Part B covers 80% of the Medicare-approved amount for outpatient physical therapy services after the annual Part B deductible has been met. The patient is responsible for the remaining 20% coinsurance. Medicare Advantage plans may have varying costs and coverage specifics, but they must offer at least the same level of coverage as Original Medicare.

What if my therapy exceeds the cost threshold?

If the total cost of therapy services exceeds $2,110, a healthcare provider must indicate that the therapy is still medically necessary for Medicare to continue coverage. When physical therapy costs exceed $3,000, Medicare may require a targeted medical review to ensure appropriate billing and continued medical necessity.

Which types of therapy are covered by Medicare?

Medicare covers several types of therapy if they are deemed medically necessary by a doctor or healthcare provider. This includes physical therapy, occupational therapy, and speech-language pathology services. These therapies can be covered under Medicare Part A (inpatient services) and Part B (outpatient services).

Are there Medicare Advantage plans for physical therapy coverage?

Yes, Medicare Advantage plans, which are provided by private insurance companies, cover physical therapy services. These plans include the benefits of Medicare Parts A and B, and often have specific network requirements. Additionally, therapy must continually be evaluated for effectiveness and medical necessity.

Can I appeal a Medicare denial for physical therapy?

Yes, individuals have the right to appeal a denial of Medicare coverage for physical therapy. The appeals process involves reviewing the denial notice, gathering supporting documentation, contacting Medicare, submitting a written appeal, following the specified appeals process, and seeking assistance if needed.

Where can outpatient therapy be received?

Outpatient therapy covered by Medicare can be received at several locations, including doctors' offices, hospital outpatient departments, outpatient rehabilitation facilities, skilled nursing facilities (SNFs), and at home through home health agencies.

What is the patient responsibility for outpatient therapy?

For outpatient therapy under Medicare Part B, coverage begins after meeting the annual Part B deductible. Medicare then covers 80% of the Medicare-approved amount, with the patient responsible for the remaining 20% coinsurance.

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