Does Medicare cover physical therapy, and if so, how much coverage do they provide? My 66 year old husband was recently diagnosed with Parkinson’s disease and will need ongoing physical therapy to help him move.
— Worried Wife
Yes, Medicare actually pays for physical therapy along with occupational and speech therapy too if he needs it as long as it’s prescribed by his doctor. You’ll also be happy to know that Medicare has no limits on how much you’ll pay for therapy services, but there is an annual coverage cap that you should be aware of. Here’s what you should know:
To get Medicare Part B — which covers outpatient care — to help cover your husband’s physical therapy, it must be deemed medically necessary and will need to be prescribed by his doctor. The same goes for occupational and speech therapy.
He can obtain these services as an outpatient in a variety of places, such as a doctor or therapist’s office; in a hospital clinic; in an outpatient rehabilitation facility; in skilled nursing facilities if he is being treated as an outpatient; and at home through a therapist connected to a home health agency when he is not eligible for the Medicare 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). You will be responsible for the remaining 20% unless you have supplemental insurance.
But be aware that if your therapy costs reach $2,230 in a calendar year (2023), Medicare will require your provider to confirm that your therapy is still medically necessary. Medicare used to set annual caps on what it would pay for outpatient therapeutic services, but the cap was lifted a few years ago.
You also need to know that treatment recommended by a physiotherapist but not prescribed by a physician is not covered. In this situation, the therapist is required to give your husband written notice, called an Advance Beneficiary Notice of Non-Coverage or ABN, that Medicare may not pay for the service. If he chooses to go ahead with the therapy, he agrees to pay in full.
If your husband needs physical therapy in an inpatient rehabilitation facility, such as a skilled nursing facility or at your home after a hospital stay lasting at least three days, Medicare Part A – which provides hospital coverage – will pay for account.
To be eligible, your doctor will need to certify that your doctor has a medical condition that requires rehabilitation, ongoing medical supervision, and coordinated care from your doctors and therapists working together.
Whether you will incur direct costs such as deductibles and co-insurance, and how much they will cost, will depend on the treatment setup and how long it lasts. For more information about the direct costs of inpatient therapy, see Medicare.gov/coverage/inpatient-rehabilitation-care.
Medicare Advantage coverage
If your husband is enrolled in a Medicare Advantage plan (such as an HMO or PPO), those plans should cover everything that is included in the original Medicare Part A and Part B coverage. However, some Advantage plans may require that a person use physiotherapy practice services within an agreed network. If they have an Advantage plan, you will need to contact your specific plan before selecting a physical therapy provider to confirm they are in-network.
If you have additional questions about coverage and the cost of therapy services, call Medicare at 800-633-4227 or contact the State Health Insurance Assistance Program (SHIP), which provides free Medicare counseling . Visit ShipHelp.org or call 877-839-2675 to connect with a local SHIP advisor.
Send your senior questions to: Savvy Senior, PO Box 5443, Norman, OK 73070, or visit SavvySenior.org. Jim Miller is a contributor to the NBC Today program and author of the book “The Savvy Senior”.