Medicare coverage for physical therapy is available for medically necessary reasons. The American Physical Therapy Association classifies physical therapists as credible healthcare providers.
Offering care to help patients regain normal physical movement and ability. Services also prevent future impairments, disabilities, diseases, and other conditions.
Medicare Coverage for Physical Therapy Benefits
Primary doctors often prescribe physical therapy to patients; referring them to a specialist for treatment. Although, the cost of service for beneficiaries will vary among plans.
The national health-care program helps pay for any medically necessary physical therapy services after a doctor orders them. The location of treatment is important, some benefits depend on where a patient receives services.
For instance, Part B offers coverage for most physical therapy services. However, treatment must be in an outpatient facility, in-network hospitals, or doctor’s office.
Part B pays 80% of charges allowable, beneficiaries cover the remaining 20% of the cost.
Coverage begins after the Part B deductible is met. The same rules apply for other medically necessary therapy services, like occupational or speech-language therapy.
Physical Therapy Services at Home
While not everyone can receive services in an outpatient setting. For some, their condition requires at-home treatment.
Parts A and B offer home health benefits that may cover the entire cost. For such at-home benefits, beneficiaries must first meet the requirements. This means patients must be under the care of a physician. Physical therapists must be part of their care plan.
Additionally, providers must certify patients are homebound. Only qualifying physical therapists may provide in-home services.
Home benefits are available for health conditions that can reasonably improve using physical therapy services. The same applies to maintain a condition from getting worse.
However, coverage is for a part-time basis. Coverage doesn’t include at-home health services for long-term use. The costs are 20% of allowable charges. Charges include costs of any DME (durable medical equipment) needed as part of treatment.
Medicare Physical Therapy Caps
In past years, Medicare put an annual limit on the number of therapy services. The costs of all therapy, both physical and occupational and speech-language pathology were part of the annual therapy cap.
Let’s look at Tom’s situation for instance. Tom was in a severe motorcycle accident and had extensive knee and foot surgery. Even worse, he had broken both wrists among other injuries.
The amount of both Tom’s physical and occupational therapy necessary for his recovery was past the cap amount.
In 2018, the elimination of therapy caps was successful. Congress no longer restricts patients to the number of services a person may receive during a calendar year.
While this may be true, some rules for the cost of coverage still applies.
Annual Limits for Physical Therapy with Medicare
Limits for physical therapy are shared with speech therapy. Meanwhile, occupational therapy has its own annual limit amount.
Health-care providers must provide additional information in medical records once charges reach a specific amount.
Occupational therapy (OT) services – $1,980. Physical therapy (PT) and speech-language pathology (SLP) costs may reach $1,980 combined within a calendar year.
Once this amount reaches $3,700, Medicare may review a patient’s claim. Claim reviews determine whether coverage continues or not.
Therefore, doctors must provide adequate information about a patient’s condition. Justifying the use of continued therapy. Otherwise, Medicare doesn’t cover any additional therapy services.
Advance Beneficiary Notice of Noncoverage
Should coverage end, providers must give patients a notice explaining the situation. Formally, this notice is an Advance Beneficiary Notice of Noncoverage (ABN).
The ABN means patients may end current therapy or continue treatment. However, patients must understand they’re agreeing to pay out-of-pocket for future services.
How Much Does Therapy Cost Under Medicare
Tom’s situation is a perfect example. Tom’s OT services are now $2,500. PT and SLP treatment costs are up to $3,900. He must continue all forms of therapy to recover.
Without proper therapy, he may not be able to function independently.
He’s in luck! His occupational therapist notes in his file that treatment is medically necessary. Reason being, to help him function with daily activities.
He struggles with simple tasks during his day-to-day; like going to and from the bathroom or changing his clothes.
Tom’s physical therapist notes that further treatment is also vital to his condition and overall health. Tom needs to re-learn how to walk, write, use his hands and more.
Lastly, his Speech pathologist was sure to include many notes about Toms’ current state. Including, due to traumatic brain injury – he’s relearning how to swallow and eat. Meaning, treatment is crucial for him.
Coverage for therapy services will continue as he recovers. On the other hand, if not enough documentation is found, coverage is often denied.
In that case, continuing services and treatments become an out-of-pocket expense. Unless you file an appeal; however, filing an appeal doesn’t guarantee coverage.
Medicare Advantage Plan Physical Therapy Benefits
Certain benefits for therapy may be different under Medicare Advantage (MA) plans. All MA policies must offer the same basic level of coverage as Original Medicare.
Moreover, Advantage plans provide coverage through private insurance companies that work with Medicare. Therefore, additional benefits like routine hearing, vision and dental, and prescription drug coverage are part of the entire plan.
Nevertheless, patients with MA coverage should contact their plans directly to ask about physical therapy benefits. Services that a plan doesn’t offer coverage for may lead to out-of-pocket costs, that can get expensive.
Find out how much testing will be, and the cost of services by talking to your doctor. Amounts may change depending on several things. Such as other insurances, doctor costs, if the provider accepts Medicare assignment, type of facility and location of treating facility.
Get Medicare Supplement Coverage to Help Pay for Physical Therapy
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