Tuesday, June 18, 2024

How Medicare Covers Physical Therapy Services

Dear Savvy Senior,

Does Medicare cover physical therapy, and if so, how much coverage do they provide? My 66-year-old husband was recently diagnosed with Parkinson’s disease and will need ongoing physical therapy to help keep him moving.

Worried Wife

Dear Worried,

Yes, Medicare does indeed pay for physical therapy along with occupational and speech therapy too, if he needs it, as long as it’s prescribed by his doctor. You’ll also be happy to know that Medicare has no limits on how much it will pay for therapy services, but there is an annual coverage threshold you should be aware of. Here’s what you should know.

Outpatient Therapy

To get Medicare Part B – which covers outpatient care – to help cover your husband’s physical therapy, it must be considered medically necessary and will need to be ordered by his doctor. The same holds true for occupational and speech therapy.

He can get these services as an outpatient at a number of places like a doctor or therapist office; in a hospital outpatient department; at an outpatient rehabilitation facility; at skilled nursing facilities if he is being treated as an outpatient; and at home through a therapist connected with a home health agency when he is ineligible for Medicare’s home health benefit.

For outpatient therapy, Medicare will pay 80 percent of the Medicare-approved amount after you meet your Part B deductible ($226 in 2023). You will be responsible for the remaining 20 percent unless you have supplemental insurance.

But be aware that if his therapy costs reach $2,230 in a calendar year (2023), Medicare will require his provider to confirm that his therapy is still medically necessary. Medicare used to set annual limits on what it would pay for outpatient therapeutic services, but the cap was eliminated a few years back.

You also need to know that treatment recommended by a physical therapy provider but not ordered by a doctor is not covered. In this situation, the therapist is required to give your husband a written notice, called an Advance Beneficiary Notice of Noncoverage or ABN, that Medicare may not pay for the service. If he chooses to proceed with the therapy, he is agreeing to pay in full.

Inpatient Therapy

If your husband happens to need physical therapy at an inpatient rehabilitation facility like at a skilled nursing facility or at your home after a hospitalization lasting at least three days, Medicare Part A – which provides hospital coverage – will pick up the tab.

To be eligible, his doctor will need to certify that he has a medical condition that requires rehabilitation, continued medical supervision, and coordinated care that comes from his doctors and therapists working together.

Whether you incur out-of-pocket costs such as deductibles and coinsurance, and how much they are, will depend on the setting for the treatment and how long it lasts. For more information on inpatient therapy out-of-pocket costs see Medicare.gov/coverage/inpatient-rehabilitation-care.

Medicare Advantage Coverage

If your husband is enrolled in a Medicare Advantage plan (like an HMO or PPO), these plans must cover everything that’s included in original Medicare Part A and Part B coverage. However, some Advantage plans may require a person to use services from physical therapy practices within an agreed network. If he has an Advantage plan, you’ll need to contact his specific plan before selecting a physical therapy provider to confirm they’re within the network.

More Questions?

If you have other questions about coverage and costs for therapeutic services, call Medicare at 800-633-4227 or contact your State Health Insurance Assistance Program (SHIP), which provides free Medicare counseling. Visit ShipHelp.org or call 877-839-2675 to connect with a local SHIP counselor.

Send your senior questions to: Savvy Senior, P.O. Box 5443, Norman, OK 73070, or visit SavvySenior.org. Jim Miller is a contributor to the NBC Today show and author of “The Savvy Senior” book.

 

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