Does Medicare Cover Physical Therapy?

Key Takeaways:

• Medicare Part B (outpatient services) covers medically necessary physical therapy.

• Physical therapy can be recommended by a doctor or other healthcare provider. This includes a nurse practitioner, nurse specialist or physical assistant.

• Physical therapy can be subject to Medicare Part B excess charges if the services provider does not accept Medicare Assignment.

• Medicare Part B does not limit how much it will pay for physical therapy in a given year.

• Medicare Advantage Plans can add limits to  your Physical Therapy and Home Healthcare. 

What Is Physical Therapy?

Physical therapy (PT) is a medical evaluation or treatment, for injury or disease, used to improve or restore physical functions.

Physical therapy can include exercise, physical manipulation or stretching to improve mobility and strength. In addition physical therapy

• assesses and treats injuries and diseases that impact your normal ability to function

• can reduce pain

• boosts or maintains current physical function or slows a decline in strength or function. 

• Improve comfort during hospice.

Does Medicare cover physical therapy services? Yes. Read on for more details.

I should note, chiropractic care is not considered physical therapy and is only covered by Medicare on a very limited basis.   

How Much Physical Therapy Does Medicare Cover?

If your doctor or another health care provider, like a nurse practitioner, clinical nurse specialist, or physician assistant certifies it is a medical necessity, Medicare covers physical therapy as part of its Medicare Part B medical insurance for outpatient therapy services.

Medicare Part B does not limit how much it will pay for physical therapy in a given year.

Generally, after the annual deductible, Medicare Part B covers 80% of the cost of medically necessary outpatient physical therapy services, such as evaluation and treatment for conditions like arthritis, back pain, and other musculoskeletal disorders.

How Many Physical Therapy Sessions Does Medicare Cover?

There is no limit on the number of physical therapy sessions that Original Medicare covers. If you have added a Medicare supplement to your Original Medicare your costs for coverage can be as low as just a few hundred dollars per calendar year with no per session copays.

Medicare Advantage Plans, however, can limit your physical therapy sessions and/or add additional copays per session. You must check the benefits of your specific plan.

What Is the Medicare 90-day Rule for Physical Therapy?

Medicare rules require extra documentation to confirm that the patient needs additional therapy beyond the original plan of care. And even if the treatment does go according to the plan, Medicare requires recertification by the physical therapist after 90 days of treatment.

Your unique plan of care will outline the frequency and duration of treatment. In it, the providers specify how much therapy time they think is medically necessary to achieve the patient’s functional goals.

Sometimes your progress might be slower than expected. In this case, the licensed physical therapist must document what happened and complete recertification, and it must be signed by a physician or NPP.

Is Physical Therapy Covered at Home?

Yes, Medicare Part B medical insurance covers in-home PT from some providers like private practice therapists and certain home health care providers.

If you meet the requirements, your out-of-pocket cost may be limited to 20% of the Medicare charge. With a Medicare supplement, you may have no out-of-pocket costs.

Your financial responsibility may be more than 20% of the Medicare-approved amount for durable medical equipment like wheelchairs, walkers, and other similar medical devices and equipment.

You need to have Medicare Part A (hospital insurance) and/or Part B and meet all Medicare requirements to qualify for at-home outpatient physical therapy.

If you have a Medicare Advantage Plan, your coverage may be limited or more restrictive. Please check the benefits for your specific Medicare Advantage plan.

How Do I Qualify for Home Health Benefits?

1) You are under the care of a doctor.

2) You must have a specific plan of care your doctor has created and regularly reviews and recertifies.

3) A doctor must certify that you require one or more of the following:

• Intermittent skilled nursing care other than drawing blood.

• Physical therapy scheduled for a reasonable period of time-specific, safe, and effective treatment for your condition by a Medicare-approved provider.

• You are homebound as defined by Medicare.

Things to Keep in Mind for Home Health Services

You will not qualify for home physical therapy benefits if you require more than part-time skilled nursing care.

If you attend adult daycare, you might still get home services from a physical therapist.

Medicare and Inpatient Physical Therapy

While some people may need outpatient physical therapy or treatment in a hospital outpatient department, others will require the care of an inpatient physical therapist.

Medicare Part A covers medically reasonable and necessary care you will receive in an inpatient rehabilitation facility or unit. It is sometimes referred to as inpatient rehabilitation facilities, IRF, acute care rehabilitation centers, or rehabilitation hospitals.

You might require inpatient physical therapy in a rehabilitation hospital or inpatient facility if you are

• recovering from a serious disease, surgery, or injury

• need a high level of specialized care that can’t be offered in another setting (for example, your home or a skilled nursing facility).

Medicare-covered services for physical therapy in rehabilitation hospitals can include:

• Medical care and rehabilitation skilled nursing facilities. nursing

• Social worker assistance

• Physical, occupational, and speech therapy

• Orthotic and prosthetic services

• Psychological services

Your doctor must certify that you have a medical condition that needs

• intensive rehabilitation to be able to function properly and independently.

• continued medical supervision in terms of physical therapy (that can’t be provided in another environment like a skilled nursing facility).

• coordinated care ; your doctors and a physical therapist working together.

You must require all of the following services for a qualifying hospital stay:

• 24-hour access to a doctor (you need direct doctor involvement at least every 2-3 days)

• 24-hour access to a registered nurse with specialized training or experience in rehabilitation

• Intensive therapy of at least 3 hours a day (but all situations are still looked at on an individual basis)

• A coordinated team of providers that includes a doctor, a rehabilitation nurse, and a therapist.

If you are eligible for Medicare-covered care in a rehabilitation hospital, you will have the same benefits and pay the same out-of-pocket price as for any other inpatient hospital stay.

On a related note, Medicare also covers Acupuncture if needed for chronic back pain.  Check out my blog post on Medicare coverage of acupuncture for details. 

Does Medicare Advantage Cover Physical Therapy?

Yes, Medicare Advantage plans are required by law to provide benefits from the same categories as Original Medicare, which includes coverage for medically necessary physical therapy services.

However, not every Medicare Advantage plan offers the same amount of physical therapy. They often have a benefit cap. The specifics of the coverage and therapy cap may vary depending on the plan. Additionally, you may need a referral from your primary care physician for physical therapy services, depending on your Medicare Advantage plan.

Your doctor must also get pre-authorization from the insurance company to use Medicare coverage for physical therapy benefits.

It is common for Medicare Advantage plans to not allow all the physical therapy sessions your doctor would recommend if he/she were not constrained by the Advantage plan.

How Does My Medigap Plan Cover Physical Therapy?

Medicare supplement insurance plans are offered by private insurance companies and typically, do not cover physical therapy services directly. Instead, Medicare Supplement Plans (aka Medigap) will usually pay the 20% Part B coinsurance and copays after the Part B deductible, thus reducing your out-of-pocket costs compared to Original Medicare.

Medicare pays their portion first, then the supplement often pays the balance.

Most Medigap plans cover the Medicare Part A deductible and homebound coinsurance costs. Thanks to this, your physical therapy costs less.

For specifics on the benefits of your Medicare supplement, check with or agent or the Medigap benefit table found here. With a supplement, you will not pay the full cost of therapy.

Does Medicare Cover Physical Therapy for Back Pain?

Medicare does cover physical therapy for back pain if it is medically necessary and prescribed by a doctor for the treatment of a specific condition or injury. Back pain is a common reason for seeking physical therapy services, and Medicare recognizes that.

Keep in mind that Original Medicare doesn’t cover the cost of massage therapy (for back pain or other issues). The Centers for Medicare and Medicaid Services (CMS) has classified massage therapy as an “alternative and complementary medicine.” For that reason, Medicare doesn’t pay for massage therapy, even if used to treat medical issues. Beware of that in case physical therapists suggest massage therapy.

Some Medicare Advantage plans may cover some of the massage therapy for back pain cost, but certain conditions must be met.

How Can I Find Out if Medicare Will Cover My Physical Therapy?

Your doctor can help you understand if physical therapy is medically necessary for your specific condition or injury, and can provide you with a referral if needed. They can definitely answer the question, does Medicare cover physical therapy?

If you have specific physical therapists in mind, you can contact their office directly to find out if they accept Medicare and what are your out-of-pocket costs? Your therapist’s office may be a good place to start.

You can also check how much Medicare covers by logging into your Medicare account or by calling Medicare. You can find out what types of physical therapy services are covered under your Medicare plan, etc.

We’re always here to answer any questions you may have on Medicare coverage, health insurance, and physical therapy.

Sources:

https://www.medicare.gov/publications/10050-Medicare-and-You.pdf

https://www.medicare.gov/publications/10988-medicare-coverage-therapy-services.pdT