Medicare Coverage of Physical Therapy
Your doctor may prescribe Medicare physical therapy for many different reasons. According to the American Physical Therapy Association, physical therapists help restore normal physical function and help prevent impairments, disabilities, and functional limitations resulting from injuries, diseases, and other conditions.
If you need physical therapy and you’re wondering what your Medicare physical therapy costs are, this article will help you understand your coverage.
What are Medicare physical therapy benefits?
Generally speaking, Medicare helps pay for any medically necessary physical therapy services your doctor orders to treat your condition. However, your Medicare physical therapy benefits depend, in part, on where you get services.
Medicare Part B generally covers physical therapy services. If you get physical therapy at the hospital, an outpatient center, or in your doctor’s office, Part B typically covers 80% of allowable charges after you meet your Part B deductible. These benefits are the same for other medically necessary therapies such as occupational therapy and speech language therapy.
However, if you need physical therapy services at home, your Medicare Part A and/or Part B home health benefits may cover 100% of the allowable charges. In order to get Medicare physical therapy benefits at home, you must meet all of the following conditions:
- You must be under a doctor’s care, and your physical therapy must be part of a care plan that is regularly reviewed by your doctor.
- You must be certified homebound by your doctor.
- The physical therapy treatments must be performed by a qualified physical therapist. If you need help finding a physical therapist who accepts Medicare in your area, you can use the Medicare Physician Compare tool.
- The home health agency providing the services must be certified by Medicare.
- Your doctor believes that your condition can reasonably be expected to improve with physical therapy, or you need physical therapy to maintain your condition and keep it from worsening.
Medicare physical therapy benefits generally won’t cover home health services that are more than part-time or intermittent in nature.
If you qualify for physical therapy home health care, you pay nothing for your therapy, and just 20% of the allowable charges for any durable medical equipment you may need as part of your treatment.
What are Medicare physical therapy caps?
In the past, Medicare imposed an annual limit, or cap, on the amount of therapy services you could get in any calendar year. The costs for physical therapy, occupational therapy, and speech language pathology all contributed to your annual therapy cap.
However, as of 2018, Congress eliminated the therapy caps. There is no longer a specific limit on the amount of physical therapy services you can receive in a calendar year, but your health care provider will have to provide extra information in your medical record when your therapy charges reach a certain amount. These amounts are:
- $2,010 for physical therapy and speech language pathology services combined
- $2,010 for occupation therapy services
Once you hit this amount, your doctor will need to note why the services are reasonable and medically necessary.
If you continue to get physical therapy or other therapy services beyond this amount, your claim may be reviewed by Medicare once the amount reaches $3,000 for either physical therapy and speech language pathology, or occupational therapy. If Medicare determines that your doctor hasn’t provided enough information to justify continued therapy, Medicare may decide not to cover any additional services.
If this happens, your health care provider or physical therapist must give you a notice explaining that Medicare may not cover additional services that aren’t considered medically necessary for your treatment. This notice is called an Advance Beneficiary Notice of Noncoverage (ABN). If you get an ABN from your provider, you can either end your physical therapy, or continue with your treatments understanding that you agree to pay for them yourself.
What are Medicare Physical Therapy benefits with Medicare Advantage plans?
If you have a Medicare Advantage plan, your Medicare physical therapy benefits may be slightly different. Medicare Advantage plans must provide the same level of benefits as Original Medicare, at a minimum. However, because these plans are offered by private insurance companies, they are free to offer extra benefits in addition to those under Part A and Part B. If you have a Medicare Advantage plan, check with your plan administrator or your plan documents to see how it covers physical therapy.
Do you have any questions about Medicare physical therapy? Feel free enter your zip code on this page to browse Medicare plan options in your area.