When does Medicare cover physical therapy?
Medicare Part B will help to pay for outpatient PT thatâ€™s medically necessary. A service is considered medically necessary when itâ€™s needed to reasonably diagnose or treat a condition or illness. PT can be considered necessary to:
- improve your current condition
- maintain your current condition
- slow further deterioration of your condition
For PT to be covered, it must involve skilled services from a qualified professional like a physical therapist or doctor. For example, something like providing general exercises for overall fitness wouldnâ€™t be covered as PT under Medicare.
Your physical therapist should give you a written notice before providing you with any services that wouldnâ€™t be covered under Medicare. You can then choose whether you want these services.
Which parts of Medicare cover physical therapy?
Letâ€™s further break down the different parts of Medicare and how the coverage provided relates to PT.
Medicare Part A is hospital insurance. It covers things like:
- mental health facilities
- rehabilitation centers
- limited stays at skilled nursing facilities
Part A can cover inpatient rehabilitation and PT services when theyâ€™re considered medically necessary to improve your condition after hospitalization.
Medicare Part B is medical insurance. It covers medically necessary outpatient services. Part B may also cover some preventive services.
Medicare Part B covers medically necessary PT. This includes both the diagnosis and treatment of conditions or illnesses that affect your ability to function.
You can receive this type of care at the following types of facilities:
- medical offices
- privately practicing physical therapists
- hospital outpatient departments
- outpatient rehabilitation centers
- skilled nursing facilities (when Medicare Part A doesnâ€™t apply)
- at home (using a Medicare-approved provider)
Medicare Part C plans are also known as Medicare Advantage. Unlike parts A and B, theyâ€™re offered by private companies that have been approved by Medicare.
Part C plans include the coverage provided by parts A and B. This includes medically necessary PT. If you have a Part C plan, you should check for information regarding any plan-specific rules for therapy services.
Part C plans can also cover some services not included in parts A and B, such as dental, vision, and prescription drug coverage. Whatâ€™s included in a Part C plan varies by plan, company, and location.
Medicare Part D is prescription drug coverage. Similar to Part C, private companies approved by Medicare provide Part D plans. The medications that are covered can vary by plan.
Part D plans donâ€™t cover PT. However, if prescription medications are a part of your treatment or recovery plan, Part D may cover them.
Medigap is also called Medicare supplement insurance. These policies are sold by private companies and can cover some costs that arenâ€™t covered by parts A and B. This can include:
- medical care when youâ€™re traveling outside the United States
Although Medigap may not cover PT, some policies may help to cover the associated copayments or deductibles.
How much does physical therapy cost?
The cost of PT can vary greatly and many factors can affect the cost, including:
- your insurance plan
- the specific type of PT services that you need
- the duration or number of sessions involved in your PT treatment
- how much your physical therapist charges
- your location
- the type of facility youâ€™re using
Copay can also be a bigfactor in PT costs. In some cases, the copay for a single session can be as high as $75. If you need to have many sessions of PT, this cost can quickly add up.
A study from 2019 found that the average PT expenditure per participant was $1,488 per year. This varied by diagnosis, with neurological conditions and joint replacement expenditures being higher while genitourinary conditions and vertigo were lower.
Coverage and payments
Once youâ€™ve met your Part B deductible, which is $203 for 2021, Medicare will pay 80 percent of your PT costs. Youâ€™ll be responsible for paying the remaining 20 percent. Thereâ€™s no longer a cap on the PT costs that Medicare will cover.
After your total PT costs exceed a specific threshold, your physical therapist is required to confirm that the services provided remain medically necessary for your condition. For 2021, this threshold is $2,110.
Your physical therapist will use documentation to show that your treatment is medically necessary. This includes evaluations of your condition and progress as well as a treatment plan with the following information:
- the specific type of PT youâ€™ll be receiving
- the long-term goals of your PT treatment
- amount of PT sessions youâ€™ll receive in a single day or single week
- total number of PT sessions needed
When total PT costs exceed $3,000, a targeted medical review may be performed. However, not all claims are subject to this review process.
Which Medicare plans may be best if you need physical therapy?
Medicare parts A and B (original Medicare) cover medically necessary PT. If you know youâ€™ll need it in the coming year, having just these parts may meet your needs.
If youâ€™re concerned about additional costs that arenâ€™t covered by parts A and B, you may want to think about adding a Medigap plan. This can help to pay for things like copays, which can add up during PT.
Part C plans include whatâ€™s covered in parts A and B. However, they may also cover services that arenâ€™t covered by these parts. If youâ€™ll need coverage of dental, vision, or fitness programs in addition to PT, consider a Part C plan.
Part D includes prescription drug coverage. It can be added to parts A and B and is often included in Part C plans. If you already take prescription medications or know that they may be a part of your treatment plan, look into a Part D plan.
Medicare Part B covers outpatient PT when itâ€™s medically necessary. Medically necessary means that the PT youâ€™re receiving is required to reasonably diagnose or treat your condition.
Thereâ€™s not a cap on the PT costs that Medicare will cover. However, after a certain threshold your physical therapist will need to confirm that the services youâ€™re receiving are medically necessary.
Other Medicare plans, such as Part C and Medigap, can also cover costs associated with PT. If youâ€™re looking at one of these, remember to compare several plans before selecting one since coverage can vary by plan.
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