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In this article, we will go over How Much Does Medicare Pay For Physical Therapy? and which parts of Medicare cover physical therapy?

Physical therapy, also known as PT, uses specially designed equipment and exercises to support you in regaining or improving your previous physical abilities. Physical therapists are highly trained health care professionals who use massage, heat treatments, and exercise to treat patients’ injuries, diseases, or physical deformities. Physical therapy can aid in the recovery of movement and the reduction of pain and discomfort caused by injuries, chronic conditions, or disabilities. Medicare covers inpatient and outpatient physical therapy services, but there are some restrictions.

While Medicare covers some physical therapy, it does not cover the entire cost. Medicare will pay a portion of your physical therapy costs if your doctor specifies that the treatment is medically reasonable and necessary. If the treatment is recommended by a physical therapist, but not ordered by a doctor, Medicare will not pay.

Individuals are usually required to pay a deductible and a copayment. Although there is no spending limit on physical therapy sessions under Medicare, once the cost reaches $2,110, a person’s healthcare provider must indicate that their care is medically necessary for Medicare to continue coverage.

How much does Medicare Pay For Physical Therapy?

Does Medicare Cover Physical Therapy?

Physical therapy (PT) that is medically necessary can be covered by Medicare. After you’ve met your Part B deductible, Medicare will cover 80% of your physical therapy costs.

Physical therapy can be an important part of the treatment or recovery process for a variety of conditions. Its primary goals are to restore functionality, relieve pain, and promote increased mobility. Physical therapists collaborate with you to treat or manage a wide range of conditions, such as musculoskeletal injuries, stroke, and Parkinson’s disease.

When does Medicare cover physical therapy?

Medicare Part B will help to pay for outpatient PT that’s medically necessary. A service is considered medically necessary when it’s needed to reasonably diagnose or treat a condition or illness. Physical therapy can be considered necessary to:

  • maintain your current condition
  • improve your current condition
  • slow further deterioration of your condition

Physical therapy must involve skilled services from a qualified professional, such as a physical therapist or doctor, in order to be covered. For example, providing general exercises for overall fitness would not be considered PT under Medicare.

Before providing you with any services that are not covered by Medicare, your physical therapist should provide you with written notice. You can then decide whether or not you want these services.

Which parts of Medicare cover physical therapy?

Let’s take a closer look at the various parts of Medicare and how the coverage relates to Physical Therapy.

Medicare Part A

Medicare Part A is hospital insurance. It covers things like:

  • inpatient stays at facilities like:
    • hospitals
    • mental health facilities
    • rehabilitation centers
    • limited stays at skilled nursing facilities
  • limited home healthcare
  • hospice care

Part A may cover inpatient rehabilitation and physical therapy services if they are considered medically necessary to improve your condition after hospitalization.

Medicare Part B

Medicare Part B provides medical coverage. It provides coverage for medically necessary outpatient services. Some preventive services may also be covered under Part B.

Part B of Medicare covers medically necessary physical therapy. This includes the diagnosis as well as the treatment of conditions or illnesses that impair your ability to function.

You can receive this type of care at the following types of facilities:

  • medical offices
  • privately practicing physical therapists
  • outpatient rehabilitation centers
  • hospital outpatient departments
  • skilled nursing facilities (when Medicare Part A doesn’t apply)
  • at home (using a Medicare-approved provider)

Medicare Part C

Medicare Part C plans are also referred to as Medicare Advantage plans. Unlike parts A and B, they are provided by private companies that have been approved by Medicare.

Part C plans include coverage from parts A and B. This includes PT which is medically necessary. If you have a Part C plan, you should look into any plan-specific rules for therapy services.

Part C plans may also include dental, vision, and prescription drug coverage, which are not included in Parts A and B. What is included in a Part C plan varies depending on the plan, company, and location.

Medicare Part D

Prescription medication coverage is provided by Medicare Part D. Part D plans are provided by private companies that have been approved by Medicare, similar to Part C. The medications covered by each plan may differ.

Part D plans do not cover physical therapy. Part D may cover prescription medications if they are part of your treatment or recovery plan.

Medigap

Medigap is also known as Medicare supplement insurance. Private companies sell these policies, which can cover some costs not covered by parts A and B. This can include:

    • Deductible: This is an annual amount that a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
    • Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
    • Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
    • medical care when you’re traveling outside the United States

Although Medigap may not cover Physical Therapy, some policies may help to cover the associated copayments or deductibles.

How Much Does Medicare Pay For Physical Therapy??

The cost of physical therapy can vary greatly, and many factors can influence the cost, including:

  • your insurance plan
  • your location
  • 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 charge
  • the type of facility you’re using

Copay can also play a significant role in PT costs. The copay for a single session can be as high as $75 in some cases Trusted Source. This cost can quickly add up if you need a lot of PT sessions.

According to a 2019 study, the average PT expenditure per participant was $1,488 per year. This varied by diagnosis, with neurological conditions and joint replacements costing the most, while genitourinary conditions and vertigo cost the least.

Costs When Medicare Covers Physical Therapy 2022

 

  • Days 1 to 60
$1,556 deductible (unless you’ve already met your deductible in this benefit period.)
  • Days 61 to 90
$389 coinsurance each day.
  • Days 91 and beyond
$778 coinsurance for each “lifetime reserve day.” You have 60 of these over your lifetime.
  • Each Day After Your Lifetime Reserve Days
You will be responsible for all costs.

Coverage and Payments

Once you’ve met your Part B deductible, which is $203 in 2021, Medicare will cover 80% of your physical therapy costs. The remaining 20% is entirely your responsibility. There is no longer a cap on the amount of physical therapy that Medicare will cover.

When your total PT costs exceed a certain amount, your physical therapist must confirm that the services provided are still medically necessary for your condition. This amount is $2,110 in 2021.

Documentation will be used by your physical therapist to demonstrate that your treatment is medically necessary. This includes assessments of your condition and progress, as well as a treatment plan that includes the following details:

  • diagnosis
  • the long-term goals of your PT treatment
  • the specific type of PT you’ll be receiving
  • amount of PT sessions you’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.

 

Estimating your out-of-pocket costs

Although you may not know exactly how much PT will cost you, it’s possible to come up with an estimate. Try the following:

  • Speak with your physical therapist to get an idea of how much your treatment will cost.
  • Check with your insurance plan to find out how much of this cost will be covered.
  • Compare the two numbers to estimate the amount you’ll need to pay out-of-pocket. Remember to include things like copays and deductibles in your estimate.

Which Medicare plans may be best if you need physical therapy?

Parts A and B of Medicare (the original Medicare) cover medically necessary physical therapy. If you know you’ll need it in the next year, having just these parts may be enough. If you’re concerned about extra costs that aren’t covered by parts A and B, you should consider adding a Medigap plan. This can help to cover costs such as copays, which can add up during Physical Therapy.
Part C plans cover everything covered in parts A and B. However, they may cover services not covered by these sections. Consider a Part C plan if, in addition to Physical Therapy, you will require coverage for dental, vision, or fitness programs. Prescription drug coverage is provided under Part D. It is often included in Part C plans and can be added to Parts A and B. Consider a Part D plan if you already take prescription medications or know that they may be part of your treatment plan.

 

Medicare covers medically necessary physical therapy services. If a person is not sure whether Medicare will cover their physical therapy, they can ask their provider before starting their course of treatment.

When an individual goes to a physical therapy session and expects to pay with Medicare, the physical therapy practice should issue them a notification if it is possible that Medicare will not cover the required physical therapy services. This helps a person minimize unexpected healthcare costs.

 

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