If you’re covered by Medicare and have an illness or injury that requires physical therapy, you may wonder, “what does Medicare cover?” More specifically, you’ll likely want to know “does Medicare cover physical therapy?”
In this MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. article, we will look at how Medicare covers physical therapy and guide you through the process of verifying your benefits.
- Physical therapy can be used to treat and improve a wide array of physical conditions.
- Medicare provides coverage for medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. physical therapy.
- Medicare Advantage members have coverage for medically necessary physical therapy, but you may be restricted on which service providers you can use.
- Medicare will cover up to $2,150 for physical therapy service fees before you require your doctor to order it as medically necessary.
- Physical therapy services are covered by Medicare when performed by a certified health care professional at a Medicare-approved facility.
- If your Medicare coverage for a physical therapy treatment is denied, you can file an appealAn appeal is an action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage plan, or your Medicare Part D plan. with evidence for why the physical therapy is medically necessary.
What Is Physical Therapy?
Physical therapy is a rehabilitative health treatment that uses specially designed exercises and equipment to help patients regain or improve their physical abilities after a physical injury1sportsmedicine.mayoclinic.org, “Physical Therapy“, Accessed November 22, 2021. Examples of physical conditions that can be improved by physical therapy include:2instituteforathleticmedicine.com, “How can physical therapy help?“, Accessed November 22, 2021
- Back and joint pain
- Carpal tunnel and trigger finger
- Parkinson’s disease
- Cystic fibrosis
- Cerebral palsy
- Muscular dystrophy
- Tennis elbow
- Pelvic floor dysfunction
Does Medicare Cover Physical Therapy?
Yes! Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services., which covers most outpatient services, covers physical therapy when it is medically necessary. The laws governing Medicare no longer set a limit on how much it pays for physical therapy in a calendar year.3Medicare.gov, “Physical therapy“, Accessed November 22, 2021 If you are covered by Original Medicare, your benefits will be different than coverage under a Medicare Advantage planMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B)..
With a Medicare Advantage plan, you have all the coverage of Parts A and B, plus additional services and benefits. If you have a Medicare Advantage plan, you may be required to use an approved physical therapist in your plan’s network4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 22, 2021.
How Much Will I Have To Pay?
Medicare is a shared-cost program. For most outpatient services, you pay 20 percent of the cost after you meet your annual deductibleA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.. Medicare pays the other 80 percent of the approved amount.5Medicare.gov, “Part B costs”, Accessed November 22, 2021 If you have a Medigap policy that covers the Part B coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. , it will cover its share of your physical therapy sessions.
Medicare covers up to $2,150 (2022 amount) for physical therapy before your doctor must specify your care is medically necessary. And since Medicare pays 80 percent of this cost, your portion is $430.6CMS.gov, “Therapy Services”, Accessed November 22, 2021
If you have a Medicare Advantage plan, you will likely have a copay instead of the 20 percent coinsurance. CopaysA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service. vary by plan.4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 22, 2021 If you have a Medicare SupplementMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. plan to help cover some of the gaps in your Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage., what you pay will depend on the plan you have7Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 22, 2021.
The specific amount you will pay for physical therapy services will depend on the type of Medicare plan you have, how much your doctor charges for their services, and the type of facility where the service is provided. Always discuss costs with your healthcare provider, so you have a clear understanding of your financial responsibility.
How Do I Know If My Therapy Is Medically Necessary?
Medicare defines medically necessary as “services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.” If your provider is a professional physical therapy practitioner, they can help you determine if Medicare covers your therapy services.8Medicare.gov, “Glossary“, Accessed November 22, 2021
Suppose your therapy is determined by Medicare not to be medically necessary. In that case, you or your doctor will receive an Advanced Beneficiary Notice of Non-Coverage (ABN). You have the option of appealing this decision.9Medicare.gov, “Advance Beneficiary Notice of Noncoverage“, Accessed November 22, 2021.
Appealing Coverage Denial
In order to appeal for coverage, you will need to fill out a Redetermination Request Form and send it to your area’s Medicare Claims Office address. You will find their specific address in your monthly Medicare Summary Notice (MSN), located on the bottom right corner of the fourth page.10Medicare.gov, “How do I file an appeal?“, Accessed November 22, 2021
Find the Right Option For You
Does Medicare cover physical therapy after an accident or surgery? Yes, it does. As long as the physical therapy is medically necessary, it will be covered by Original Medicare or a Medicare Advantage plan.
Determining your Medicare benefits can be tricky, but MedicareWire offers plenty of help and Medicare resources to answer your questions. Check out the rest of our site for important information about Medicare Advantage plan options for your needs and budget.
- 1sportsmedicine.mayoclinic.org, “Physical Therapy“, Accessed November 22, 2021
- 2instituteforathleticmedicine.com, “How can physical therapy help?“, Accessed November 22, 2021
- 3Medicare.gov, “Physical therapy“, Accessed November 22, 2021
- 4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 22, 2021
- 5Medicare.gov, “Part B costs”, Accessed November 22, 2021
- 6CMS.gov, “Therapy Services”, Accessed November 22, 2021
- 7Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 22, 2021
- 8Medicare.gov, “Glossary“, Accessed November 22, 2021
- 9Medicare.gov, “Advance Beneficiary Notice of Noncoverage“, Accessed November 22, 2021
- 10Medicare.gov, “How do I file an appeal?“, Accessed November 22, 2021