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Medicare Coverage for Occupational Therapy

Medicare covers occupational therapy that treats or improves a condition. You may obtain services on an inpatient or outpatient basis. Also, some costs are possible since Medicare only covers a portion of care. Now, if you have supplemental insurance, you may have no copay or a small copay. Of course, some rules apply, which we go over in the content below.

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Does Medicare Cover Occupational Therapy?

As long as the occupational therapy is necessary, Medicare Part B will cover a portion of outpatient services. And any inpatient service Part A will cover.

The doctor must give proper diagnosis codes that support orders for treatment. If your request for therapy is denied, contact your doctor to ensure proper codes. Or, file an appeal form to reassess your request for care.

Doctors must prescribe therapy, provide a care plan, and regularly review it.

What are the Medicare Guidelines for Occupational Therapy?

Therapy service limits reflect the total cost, rather than a specific number of visits. The amount per service depends on the therapist providing care. One therapist may charge more than another for the same service.

The federal government wants to ensure beneficiaries aren’t taking advantage of therapy services. But, this doesn’t prevent patients from obtaining therapy. It acts more like a threshold limit.

Doctors must add billing codes to patients’ medical records once they have spent up to the limit. These codes notify the government that the patient’s therapy services exceed a certain amount. But, Medicare may review the case to ensure the therapy is still necessary.

The threshold amount for occupational therapy that Medicare pays before reviewing a patient’s case is $2,150 in 2022. Medicare does this to ensure medical necessity.

Therapists should document in their patients’ medical records why additional sessions are needed. Otherwise, they may face denial of coverage for therapy.

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Does Medicare Cover In-Home Occupational Therapy?

Home therapy services may be part of coverage for people who are unable to leave the house. Although to obtain home health services, a patient must meet specific requirements before Medicare Part A covers costs.

First, to get home health services, a person must be homebound. Medicare classifies this as someone unable to leave their home without assistance. The second requirement is to get therapy from experts. Therapists must create a care plan that focuses on improving a person’s condition or healing their injury.

Services aren’t meant to be permanent. But, therapy should expand over a fair length of time to reach the care plan goal.

FAQs

Does Part A cover occupational therapy?
Yes, Part A covers occupational therapy when a person is in a hospital. Then, Part B would cover you in an outpatient setting.
Do Medicare Advantage plans cover occupational therapy?
Medicare Advantage plans must cover at least as good as Medicare. So, yes, Part C plans will cover occupational therapy.
What if occupational therapy isn't medically necessary?
If occupational therapy isn’t medically necessary, the doctor must notify you before providing care. You will pay for these services yourself.
Where can you get occupational therapy?
Medicare covers you in a doctor’s office, rehabilitation facility, comprehensive outpatient rehab facility, skilled nursing facility, and in your home from certain therapists.

How to Get Help Paying for Occupational Therapy

Medicare covers occupational therapy, physical therapy, and speech-language pathology. But, Medicare doesn’t cover the full costs. Having a Medicare Supplement Plan (Medigap) means you get to eliminate some of the costs that you’d otherwise pay. Working with a licensed insurance representative can help you find and compare plans in your area to find one that meets your healthcare and budget needs.

Our agents can answer all your questions. We are here to help you review your options. Give us a call today at the number above to get started. You can even fill out an online rate comparison form to see your rates online.

Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Medicare Insurance Agent, she brings a wealth of knowledge and expertise to her writing.

2 thoughts on "Medicare Coverage for Occupational Therapy"

    1. Hi Robert, depending on the surgery you have, the amount of outpatient therapy needed will vary. You will need to discuss this with your physician and then notify Medicare of the upcoming therapy.

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