What parts of Medicare cover occupational therapy?
After an illness, injury, or surgery, it may be harder to perform some of the tasks of daily living. These may include combing your hair, brushing your teeth, dressing, and bathing.
OT can be used to help you regain strength and the skills needed to perform these tasks on your own. It may also help you learn how to communicate more efficiently with electronic devices, should you become unable to speak your needs aloud.
Occupational therapy is covered by original Medicare (parts A and B). Part A will cover OT thatâ€™s needed when youâ€™re an inpatient, while Part B will cover outpatient services.
If you have a Medicare Advantage (Part C) plan, it will provide at least the same coverage as original Medicare.
If you have a Medigap plan in addition to original Medicare, it may cover some of the leftover out-of-pocket costs after Medicare pays its share.
Next, weâ€™ll go over the details of how each part of Medicare covers OT.
Part A coverage
If youâ€™re hospitalized, Medicare Part A covers the costs of OT services you receive during your stay.
This type of OT may be needed if an existing disease or condition is getting worse or if you have a newly diagnosed condition or disease. You may also need inpatient OT services after a surgery.
In addition to hospital care, Part A covers the cost of OT received in:
- skilled nursing facilities
- inpatient rehabilitation centers
- assisted living facilities
Part A also covers the cost of OT that you receive at home from a home health aide.
Part B coverage
Medicare Part B covers the cost of outpatient OT services. These may be received at a therapistâ€™s office, doctorâ€™s office, hospital, clinic, or other medical facility.
To receive coverage, you must get OT from a Medicare-approved provider. You can search for approved providers in your area here.
The types of services an OT program may provide include:
- assessing your current skill level to perform daily living tasks, including determining your ability to eat and swallow
- creating a customized treatment plan designed to fit your needs and goals
- evaluating your living and work environments to determine if adaptive equipment, such as safety bars in the bathroom, is required
- exercises for balance and weight bearing
- exercises to enhance range of motion
- training for you and your caregivers on how to use durable medical equipment, such as canes and walkers
- training for your caregivers on safety techniques for your care, such as safe car transfers
- training for techniques you may need to learn to perform daily living tasks in a new way
Part C coverage
Medicare Advantage (Part C) plans are legally required to cover at least as much as original Medicare (parts A and B). So, these plans will cover OT services you need as both an inpatient and outpatient.
Your costs, including deductibles and copays, will be determined by your plan and may differ from those of original Medicare.
You may also need to choose from a list of in-network providers from your insurance company to have OT services covered.
How do I qualify for coverage?
To qualify for coverage of OT through Medicare, youâ€™ll need to be enrolled in original Medicare or a Medicare Part C plan.
Youâ€™ll need to keep up with your monthly premiums and plan payments, including your Part B premium.
Medicare will only pay for OT thatâ€™s considered medically necessary. Youâ€™ll need a referral for OT from your doctor if you exceed $2,080 in costs for these services within a calendar year.
To ensure that you receive full coverage, the provider and facility you use for OT must accept Medicare assignment. You can find a Medicare-approved provider or facility here.
What costs should I expect?
Depending on the part of Medicare thatâ€™s covering your OT services, you may see different costs. Below, weâ€™ll go over some of the costs to consider under each part of Medicare that provides coverage for OT.
Part A costs
If your claim is covered under premium-free Part A, a hospital deductible of $1,484 per benefit period will apply. This means youâ€™ll need to pay that amount out of pocket before Medicare begins covering its share.
Once you meet the deductible, inpatient coinsurance costs will also apply if your stay lasts longer than 60 days in a benefit period.
Part B costs
If your claim is covered under Part B, you must meet an annual deductible of $203 before coverage for OT services starts. Once youâ€™ve met this deductible, youâ€™ll be responsible for paying 20 percent of the Medicare-approved costs of OT services.
In addition, you must continue to pay your monthly Part B premium, which is $148.50 for most Medicare beneficiaries in 2021.
Until 2018, there was a therapy cap on Medicareâ€™s coverage for outpatient IT coverage by Part B. This cap has been repealed and is no longer in effect. However, if the cost of OT services exceeds $2,080, your doctor must confirm that theyâ€™re still medically necessary for your ongoing rehabilitation and care.
Part C costs
If you have a Part C (Medicare Advantage) plan, your out-of-pocket costs will be set by the plan you have.
What is occupational therapy?
OT can help you learn techniques to improve your fine and basic motor skills. It can also help you gain or maintain a high level of independence, which can lead to a better quality of life.
For example, with training received through OT, you may be better able to open pill bottles, removing a barrier between you and the medications you need.
By increasing muscle strength, stability, and balance, OT can help you avoid accidents after hospital discharge. It can also support you in maintaining a higher level of functioning if you have an ongoing illness or disability.
In fact, a 2016 study showed that OT reduces hospital readmissions by supporting patient safety.
What can I expect during an OT session?
Occupational therapists usually work with people during a 1-hour training session. During that period, theyâ€™ll guide you through exercises for specific conditions or areas of the body, such as your hands or feet.
You may train with props designed to support daily living tasks, such as button hooks, during your sessions. You may also do range of motion exercises, weight bearing exercises, and strength training. Some of these will also use props, such as light weights or balls.
OT exercises also may be geared toward memory enhancement. Tools that support memory â€” such as crossword puzzles, jigsaw puzzles, and matching games â€” may be used.
OT may be beneficial for a wide range of conditions including:
- Parkinsonâ€™s disease
- Alzheimerâ€™s disease
- multiple sclerosis
- ankylosing spondylitis
- hip or knee replacement
Medicare plan options and costs are subject to change each year.
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