Does Medicare cover physical therapy services?

LEARN HOW YOUR PLANNED GIFT CAN HELP THE AMERICAN LEGION

How much coverage does Medicare provide for physical therapy? My spouse was recently diagnosed with Parkinson's disease and will need ongoing therapy.

Medicare can cover the cost for physical therapy, along with occupational and speech therapy, if it is medically necessary and prescribed by a health-care professional. Fortunately, Medicare has no limits on how much it will pay for therapy services, but there is an annual coverage threshold to be aware of. Here is what you should know.

Outpatient Therapy 

To get Medicare Part B (which covers outpatient care) to help cover your spouse's physical therapy, it must be considered medically necessary and will need to be ordered by the doctor. The same holds true for occupational and speech therapy.

Individuals can receive these services as an outpatient at a number of places. Services can be provided by a doctor’s or therapist’s office, in a hospital outpatient department, at an outpatient rehabilitation facility, at skilled nursing facilities if being treated as an outpatient, or at home through a home-health-agency therapist if your spouse is ineligible for Medicare's home health benefit.

For outpatient therapy, Medicare will pay 80% of the Medicare-approved amount after you meet your Part B deductible ($226 in 2023). Patients will be responsible for the remaining 20% unless it is covered by supplemental insurance.

Please note that if your spouse's therapy costs reach $2,230 or more in the 2023 calendar year, Medicare will require their health-care provider to confirm that the therapy is still medically necessary. Medicare previously restricted coverage on outpatient therapeutic services, but the cap was eliminated a few years ago.

Keep in mind that treatment recommended by a physical therapy provider but not ordered by a doctor is not covered. In this situation, the therapist is required to give the patient a written notice called an "Advance Beneficiary Notice of Noncoverage" (ABN), which says that Medicare may not pay for the service along with an estimate of the costs. If the patient chooses to proceed with the therapy, it is an acknowledgment that the patient is agreeing to pay in full.

Inpatient Therapy 

If your spouse happens to need physical therapy at an inpatient rehabilitation facility, like a skilled nursing facility, or at your home after a hospitalization lasting at least three days, Medicare Part A (which provides hospital coverage) will cover the costs. To be eligible, a doctor will need to certify that the patient has a medical condition that requires rehabilitation, continued medical supervision and coordinated care that comes from doctors and therapists working together.

Whether a patient will incur out-of-pocket costs such as deductibles and co-insurance, and how much those are, will depend on the setting for the treatment and how long it lasts. For more information on inpatient therapy out-of-pocket costs visit Medicare.gov/coverage/inpatient-rehabilitation-care.

Medicare Advantage Coverage 

If your spouse is enrolled in a Medicare Advantage plan (like an HMO or PPO), these plans must cover everything that is included in Original Medicare Part A and Part B coverage. However, some Medicare Advantage plans may require a person to use services from physical therapy practices within an agreed network. If your spouse has a Medicare Advantage plan, it is best to contact the specific plan before selecting a physical therapy provider to confirm the provider is in network.

More Questions? 

If you have other questions about coverage and costs for therapeutic services, call Medicare at 800-633-4227. Your State Health Insurance Assistance Program (SHIP) also provides free Medicare counseling and is a great resource to help answer any questions. Visit ShipHelp.org or call 877-839-2675 to connect with a local SHIP counselor.

“Savvy Living” is written by Jim Miller, a regular contributor to NBC’s “Today Show.” The column, and others like it, is available to read via The American Legion’s Planned Giving program, a way of establishing your legacy of support for the organization while providing for your current financial needs. Learn more about the process, and the variety of charitable programs you can benefit, at legion.org/plannedgiving. Clicking on “Learn more” will bring up an “E-newsletter” button, where you can sign up for regular information from Planned Giving.