If you or a loved one needs physical therapy, one of the first questions that comes up is whether Medicare will cover it. The good news is that Medicare does provide coverage for many physical therapy services, but there are a few important details to understand, including where you receive care, what is considered medically necessary, and what costs you may be responsible for.
In this blog, we'll be explaining what's covered, what's not and how to find a Medicare health plan that covers the care you need.
Original Medicare does cover physical therapy, and it is covered by Medicare Part A or Medicare Part B, depending on where treatment is received. In order for physical therapy to be covered by Medicare, it must be considered medically necessary, and typically requires a plan of care from a qualified provider. Physical therapy services must also be administered by a provider who accepts Medicare assignment.
As described on Medicare.gov, physical therapy helps restore or improve movement following an injury, illness, or surgery. It can also support maintaining your current function or slowing the rate of decline.
Depending on your specific health needs, Medicare may cover physical therapy in a variety of situations. There are several qualifying conditions and circumstances that can make you eligible for coverage, including:
Outpatient physical therapy is the most common type of PT care covered by Medicare. This includes physical therapy that is provided in clinics or hospitals.
At times, Medicare does cover in-home physical therapy if you meet eligibility requirements to receive home health services.
Physical therapy is also covered by Medicare during and after a qualifying stay in a skilled nursing facility (SNF) as part of your post-surgery rehabilitation plan.
There are some instances when Medicare will not cover certain types of physical therapy, specifically those that are deemed not medically necessary. Any services that have not been prescribed by a doctor will not be covered. In some cases, maintenance therapy may also be excluded from benefits. Lastly, if the services are provided by practitioners who do not accept Medicare, those services will not be covered either.
Related Read: Alternative Health Care Coverage with Medicare
When it comes to physical therapy coverage, there isn't a strict limit on sessions covered by Medicare, although sessions provided must continue to be a medical necessity. If a patient requires extended treatment beyond the initial approval, additional documentation from the medical provider may be needed to support continued therapy.
The cost of physical therapy will vary depending on what Medicare coverage you have.
If you have Original Medicare, what you pay can vary depending on where you receive care. For outpatient services like physical therapy under Part B, you’ll pay the Medicare-approved cost until you meet your deductible, and then typically 20% coinsurance after that.
When you receive care while admitted to a hospital or in a skilled nursing facility, it’s typically covered under Part A. That means you may need to meet your Part A deductible and cover any additional cost-sharing. The amount billed will vary depending on the provider, setting and services provided.
If you have additional Medicare coverage, such as a Medigap policy or Medicare Advantage plan, you may not have any out-of-pocket responsibility after the deductible, or you may just have a set copay amount.
Medicare Advantage Plans (MA/MAPD) also cover physical therapy. If you have a Medicare Advantage Plan, you typically do not have to pay the Medicare Part A or Part B deductible. With a Medicare Part C Advantage Plan, you may pay 20% coinsurance (up to your plan's maximum out of pocket) for your physical therapy, although often you will pay a copay, which could range anywhere from $10-$50 per session.
Rather than going to any physical therapist who accepts Medicare, you will want to confirm that the provider is in-network with your Medicare Advantage plan. Each Medicare Advantage Plan is different, and if physical therapy is common or important to you, it's essential to compare closely to ensure your care is adequately covered. If you end up going to an out-of-network physical therapist, you could be responsible for up to 50%.
Understanding how your Medicare plan covers physical therapy can help you plan ahead and avoid surprises. Reviewing all your options ensures your coverage aligns with your healthcare needs.
At Twin City Underwriters, we've been helping individuals with their insurance needs for over 50 years. Our experienced Medicare brokers will help you compare all of your Medicare plan options and help you decide which plan is ideal to meet your budget and healthcare needs.
Reach out to our trusted team today to get started.
Sources:
https://www.medicare.gov/coverage/physical-therapy-services
https://www.medicare.gov/publications/10988-medicare-coverage-of-therapy-services.pdf
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