Does Medicare Cover Physical Therapy - Guidelines & Coverage

By: Meredith Miller
Published: Tuesday, September 25 2018
Last Updated: 4 years ago

Medicare boasts itself as one of the most comprehensive health insurance plans you can enroll in. So, if you’re like the millions of American seniors who rely on Medicare to help cover your healthcare costs, you may be surprised to learn that there are certain medical services your Medicare won’t cover, especially if it’s not considered medically necessary. So, if you find yourself wondering if your Medicare covers physical therapy, here’s your answer.

Does Medicare Cover Physical Therapy?

Fortunately, those who think they will need Medicare physical therapy coverage can breathe a sigh of relief because it turns out Medicare does cover physical therapy through its Part B insurance. All those who are covered by Medicare Part B are eligible for coverage as long as the requested Medicare physical therapy services are considered medically necessary and reasonable.

What Are the Guidelines?

Once you reach a certain amount in the calendar year the law requires you to obtain written confirmation from your therapy provider that the services being rendered are medically necessary and reasonable. The Medicare physical therapy provider will be required to include a special notation with your therapy claim that confirms the medical necessity and reasonableness of the services provided. Additionally, the special notation will also need to confirm that your medical records illustrate why the specific services are necessary medically.

What Is the Coverage Limit?

Congress has recently eliminated the Medicare physical therapy cap. However, there are some limits set and once they are reached, Medicare will require further confirmation of the medical necessity of the therapy services you are receiving.

Under the current law, once you have reached $2,010 worth of physical therapy services you will be required to obtain further confirmation from your therapy provider which will be added to your medical record. Also, you should note that if you are also receiving speech-language pathology services from Medicare, that is also added to your allotted usage before being required to obtain further confirmation from your therapy provider.

Even after you have complied with the requirements of the first usage limit, if you continue to receive Medicare physical therapy services throughout the year you may end up hitting the second limit, which may require additional steps for you to continue Medicare physical therapy coverage. Once you have received $3,000 worth of Medicare physical therapy and speech-language pathology services in a calendar year a contractor working with Medicare may take a look at your medical records to ensure the therapy services rendered were indeed medically necessary.

Understanding Your Medicare Benefits

Although Medicare physical therapy coverage will include everything that is medically necessary, there are times when you desire to receive certain types of physical therapy services that are technically not considered medically necessary, but they would greatly improve the quality of your life. Luckily, in these cases, there is a process via Medicare that you can use to make sure you are able to also receive these services.

Your therapy provider will be required to provide a written notice that these services are not necessary medically. This notice, known as an Advance Beneficiary Notice of Noncoverage (ABN) must be provided prior to you receiving the specific desired physical therapy services. Another thing that is important to be aware of is that if you do indeed elect to obtain these unnecessary services you will have to agree to pay for the services yourself. You may also decide to cover these costs with a Medicare Supplement insurance plan, otherwise known as Medigap.

As a part of Medicare Part B coverage, physical therapy via Medicare will follow the Part B deduction limits. Currently, this means that you will have to pay a standard $183 annual deductible. After the deductible is covered Medicare generally covers 80 percent of the costs for Medicare-approved services and procedures.

The monthly premium for Medicare Part B coverage is $134 or more, depending upon your income level. The highest monthly premium paid is $428.60 for individuals earning $160,000 per year or $320,000 annually for a married couple.