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You can access your physical therapy benefits through Original Medicare or your Medicare Advantage Plan. Medicare no longer limits how much physical therapy you can get but requires ongoing written evidence that it is still helpful and necessary for you.
You can receive physical therapy in an inpatient setting like the hospital or a skilled nursing facility, or an outpatient setting like a therapist’s clinic. You may be eligible to receive physical therapy at home as part of your home health care services or as an outpatient service. Physical therapy is covered under Medicare Parts A and B, as long as it is prescribed by a physician or non-physician practitioner and is deemed medically necessary to treat your condition.
Why is Physical Therapy Valuable?
According to the American Physical Therapy Association (APTA), physical therapy can help you regain or maintain your ability to move and function after injury or illness. Physical therapy can also help you manage your pain or overcome a disability. Physical therapists are specially trained and licensed to prescribe exercises, provide education, and give hands-on care to you in various settings.
Does Medicare Cover Physical Therapy?
Medicare covers physical therapy as a skilled service. Whether you receive physical therapy (PT) at home, in a facility or hospital, or a therapist’s office, the following conditions must be met:
- PT must always be medically necessary for Medicare to provide coverage. That means it is a treatment for your condition that meets accepted standards of medicine.
- There must always be a physician’s or non-physician practitioner’s (like a physical therapist) order to certify you need to start PT.
- You must have an ongoing medical need for PT to continue.
- You must receive PT from a provider who participates in Medicare.
Medicare will cover physical therapy under either Original Medicare Part A or Part B, or a Medicare Advantage Plan. Your coverage and how much you pay depends on your plan, your particular circumstances, and where you receive your therapy.
Several conditions must be met for Medicare to cover your physical therapy. The burden of proof that you are eligible to receive your physical therapy benefits lies with the suppliers and providers of therapy. There are rules about billing codes and documentation that the facility, therapist, or agency must follow. Medicare Part A and Part B cannot be billed at the same time. Make sure you understand what your coverage looks like and how much you may need to pay, especially if you receive physical therapy in different settings.
What Parts of Medicare Cover Physical Therapy?
Part A (hospital insurance) covers physical therapy as an inpatient service in a hospital or skilled nursing facility (SNF) if it’s a Medicare-covered stay, or as part of your home health care benefit. You are responsible for the Part A deductible for your hospital inpatient stay ($1,484 per benefit period in 2021) and a daily coinsurance if you are in a SNF longer than 20 days. There is no copay for physical therapy as part of your home health care benefit under Part A.
For instance, suppose you are in the hospital after surgery or after being treated for an acute illness like pneumonia. As you recover, physical therapy may be part of your treatment plan to ensure that you continue improving and functioning well once you are back home. Your physical therapist will provide hands-on care, education, and specific exercises you can do at home.
Sometimes, you will go directly home from the hospital and may continue to receive physical therapy services as part of your home health care benefit. Or, you may go to a Skilled Nursing Facility (SNF) from the hospital to continue your rehabilitation and recovery before you go home.
Medicare Part A
|Medicare Part A will pay for your SNF stay, including physical therapy, if:
Medicare Part B
|Part B (medical insurance) covers physical therapy you receive as an outpatient or preventive service to improve or maintain your current condition or slow decline. You may receive this service in a clinic or your home. Part B pays 80% of the Medicare-approved amount after you pay your annual deductible ($203 for 2021), and you are responsible for the 20% copay.
For instance, suppose you live at home with a chronic, progressive condition like Parkinson’s Disease. You need physical therapy to maintain your ability to function and move around without stiffness and pain. You may go to your physical therapist’s office for therapy sessions and to learn exercises you can do at home. Or, the physical therapist may come to your home, which is more convenient for you. This is not the same as physical therapy you may receive as part of your home health care benefit covered under Part A.
|Part C (Medicare Advantage) covers physical therapy as a Medicare-covered service with the same restrictions and requirements as Original Medicare. Depending on your plan, you may need a referral, prior authorization or approval, and an in-network physical therapist for your plan to pay. You will most likely pay a copay or coinsurance for outpatient physical therapy, and may have a deductible or copay for inpatient services that include physical therapy. If you have a Medicare Advantage Plan, check with your plan to understand how physical therapy is covered and what you must pay.|
|Medicare Supplement Insurance (Medigap) generally covers the 20% Part B coinsurance. Most Medigap plans cover the Part A deductible and homebound coinsurance costs. You can purchase a Medigap plan if you have Original Medicare, but not if you have a Medicare Advantage Plan.|
Does Medicare Cover In-home Physical Therapy?
Medicare Part A covers in-home physical therapy as a home health benefit under the following conditions:
- Your physician must certify the physical therapy services as medically necessary.
- Physical therapy is part of your home health plan of care that details how many visits you need and how long each will last.
- Your plan of care must be reviewed and renewed (if appropriate) at least every 60 days.
- A qualified homebound therapist provides services.
- You must be homebound; that is, you can only leave your home with considerable difficulty and require assistance to do so.
- You must receive your home health services, including physical therapy, from a Medicare-approved home health agency.
Medicare Part B covers in-home physical therapy as an outpatient or preventive service in the same way it covers physical therapy in an office or clinic. Services must still be medically necessary, but the benefit of home visits is that the physical therapist can evaluate you and prescribe exercises that apply to your home environment. You are not required to be home-bound as with Part A, but all other rules and restrictions apply.
What Are the Medicare Caps for Physical Therapy Coverage?
Medicare no longer caps medically necessary physical therapy coverage. For outpatient therapy in 2021, if you exceed $2,110 with physical therapy and speech-language pathology services combined, your therapy provider must add a modifier to their billing to show Medicare that you continue to need and benefit from therapy.
What drives whether or not Medicare will continue to help pay for your physical therapy is its effect on your condition and ability to function without pain or decline. You may receive physical therapy as an inpatient service covered by Part A or an outpatient, preventive service covered by Part B. It is up to the therapist, facility, or agency to bill Medicare using the correct billing codes. Medicare requires documentation that shows your progress and needs for ongoing therapy.
Learn More From Our Sources
- CMS | 2021 Annual Update of Beneficiary Threshold Amounts | Last accessed October 2021
- APTA | What Physical Therapists Do | Last accessed October 2021
- Medicare | Physical Therapy Coverage | Last accessed October 2021
- Medicare | Medicare Home Health Services | Last accessed October 2021
- Medicare | Medicare and You Handbook 2022 | Last accessed October 2021
- Medicare | Skilled Nursing Facility Care Coverage | Last accessed October 2021