The goal of physical therapy for those with injuries, chronic diseases, or impairments is to help them restore mobility while decreasing pain and discomfort. Physical therapy can be provided both in- and out-patient settings, however Medicare has restrictions on which settings are covered.
While Medicare does help cover the expense of physical therapy, it does not pay for all of it. A deductible and copayment are two common costs that an individual will have to shoulder.
While there is no hard cap on how much Medicare will pay for physical therapy, once expenses exceed $2,110, the patient’s doctor will need to certify that the therapy is still medically required for the patient to receive coverage.
The article below details the circumstances under which a Medicare patient would benefit from physical therapy. We also go through some things to think about while using Medicare to pay for physical therapy.
Physical therapy with Original Medicare
Medicare covers PT in many ways:
- Physical therapy as part of an outpatient rehabilitation program is covered by Medicare Part B.
- Physical therapy received during a hospital stay or subsequent rehabilitation in a skilled nursing facility is covered by Medicare Part A.
- Hospice patients may also be eligible for physical therapy services under Part A.
- If a patient fits the criteria, they may be eligible to receive coverage for physical therapy at home under Medicare Part A or Part B as part of their home health care package.
The Medicare Part B deductible must be met before outpatient physical therapy services can be paid for. There will be a $203 deductible for Medicare Part B in the year 2021. After this deductible is satisfied, the patient’s share of the Medicare-approved physical therapy cost is 20%.
During the first 60 days of receiving inpatient care, the Medicare Part A deductible is $1,484. A $371 daily coinsurance cost is charged between days 60 and 90. Medicare will pay for everything beginning on day 91, up to a maximum of 60 days.
Each time a person receives benefits, they must first pay the deductible. There is no additional coinsurance for the first 60 days of that stay or benefit period.
Physical therapy with Medicare Advantage
Private insurance companies handle the administration of Medicare Advantage, which is a packaged Medicare plan. This coverage is equivalent to Medicare’s Parts A and B, and in some cases, Part D, which pays for medication.
Physical therapy is included in Medicare Advantage plans just like it is in Medicare Parts A and B. Some Advantage plans, however, can mandate that patients only visit physical therapy clinics that are part of a predetermined network.
Before choosing a physical therapist, a patient should check with their insurance company to make sure the clinic is covered.
Limits and restrictions
Medicare will only pay for a set number of physical therapy visits if a clear course of treatment has been established.
In addition, the program will check in on a regular basis to see if the therapy is helping and if the patient still has a legitimate medical need for it. This evaluation and reporting to Medicare must be performed by a qualified medical professional, such as a physical therapist.
The following may be components of an effective physical therapy plan:
Medicare requires re-certification from the PT that therapy is medically necessary after the cost of treatment reaches $2,110.
When the sum of a patient’s PT bills reaches $3,000, Medicare may initiate a “targeted medical evaluation.” The purpose of this review is to confirm that the therapy is still medically necessary and that the provider is accurately billing for it.
Medicare will cover physical therapy sessions if they are medically necessary. There are copayments and deductibles associated with Medicare physical therapy coverage.
A patient should verify with their provider that Medicare will cover their physical therapy before beginning treatment.
A practitioner owes it to the patient to forewarn them if Medicare is unlikely to pay for the required physical therapy services before they show up for the first visit. This results in less money being spent by the patient out of pocket.
When therapy expenditures reach $2,110, Medicare demands a re-certification from the PT that the treatment is medically required.
Medicare may request a targeted medical review for physical therapy when the total cost of care exceeds $3,000. This evaluation is intended to ensure that the provider is invoicing correctly and that the therapy is still medically necessary.
Medicare will pay for physical therapy treatments if they are medically required. Physical therapy under Medicare coverage is subject to coinsurances and deductibles.
Before commencing a course of physical therapy, patients should check with their provider to see if their service will be covered by Medicare.
If it is probable that Medicare would not cover the necessary physical therapy services, the practitioner should notify the patient of this fact before they attend their first appointment. As a result, the individual’s out-of-pocket medical expenses are reduced.