Physical therapy is often an overlooked aspect of healthcare planning. However, the Medicare program allocates a significant budget for physical therapy services for its beneficiaries. Understanding what services are covered by Medicare (and which ones aren’t) is crucial when considering physical therapy options under Medicare.
Under Medicare Part B, beneficiaries get help with the costs of outpatient physical therapy, including occupational and speech therapy. These services are accessible through a variety of providers, including private practice therapists, outpatient departments of hospitals, and skilled nursing facilities. Additionally, beneficiaries have the option to receive treatment from therapists affiliated with rehabilitation agencies, offering a broad range of choices for their care.
Previously, Medicare imposed certain annual limits on these therapy services, commonly referred to as Medicare Physical Therapy Caps. However, in 2019, those spending caps were eliminated. As a result, beneficiaries can now enjoy unrestricted access to physical therapy sessions, with no limitations on the number covered by Medicare.
When using Original Medicare for physical therapy, beneficiaries might first need to meet the Part B deductible if it hasn't been met for the year. After satisfying this deductible, Medicare generally covers 80% of the costs associated with physical therapy sessions. For those with a Medigap policy, it can potentially cover the remaining 20% of coinsurance. However, it's important to remember that Medicare's coverage extends only to physical therapy sessions deemed medically necessary.
A physical therapy session is considered medically necessary if it's essential for diagnosing, treating, or monitoring a health issue. Despite the absence of caps on the number of sessions Medicare will fund, there could be instances where Medicare reviews the ongoing necessity of the therapy. In cases where Medicare decides that the ongoing therapy is no longer medically necessary, they may discontinue coverage for further sessions. Therefore, it's advisable to have your therapist consistently document the medical necessity of each session to ensure continued Medicare support.
If a Medicare provider administers a service that might not qualify as medically necessary, they are required to inform you. In this case, you’ll receive an Advance Beneficiary Notice from the provider. This notice will detail the potential non-coverage decision by Medicare. Armed with this information, you'll then have the choice to either continue with the therapy and pay the costs yourself or to discontinue the services.
Medicare Advantage plans are required to offer the same benefits as those provided under Parts A and B of Original Medicare. Given that Medicare Part B includes coverage for medically necessary physical therapy sessions, Medicare Advantage plans are also required to cover these services.
However, the specifics of cost-sharing can vary significantly between different Medicare Advantage plans. Individuals enrolled in these plans should refer to their specific plan's Summary of Benefits to understand their unique coverage details. It's also important to note that with Medicare Advantage plans, it's the plan itself, not Medicare, that determines the medical necessity of services and manages the beneficiary's care.
If you have any questions about your Medicare coverage for physical therapy or need assistance in navigating your plan, don't hesitate to reach out to us at Local Medicare Specialists. Our team is dedicated to helping you understand your benefits and ensuring you get the most out of your Medicare plan. Contact us today to schedule a consultation and take the first step toward a clearer understanding of your Medicare benefits.
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area which are United Healthcare, Aetna, Humana, Cigna, Blue Cross Blue Shield of Arizona, Centene, Devoted, and Scan. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.