Physical therapy can help people regain movement and reduce pain and discomfort due to injuries, chronic conditions, or disabilities. Medicare pays for inpatient and outpatient physical therapy services.
However, it does not cover the full cost of treatment. An individual will usually need to pay a copayment for their services.
Although Medicare does not have a spending limit on physical therapy sessions, once the cost reaches $2,080, a person’s healthcare provider will need to indicate that their care is medically necessary.
In this article, we explain when a person with Medicare may need physical therapy. We also discuss considerations to bear in mind when funding physical therapy sessions through Medicare.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare pays for physical therapy sessions under Medicare Part B. This portion of Medicare pays for preventive services, such as vaccinations, and medically necessary services.
Physical therapy usually falls under the category of medically necessary services, although some physical therapists do provide preventive services to minimize risks for injury.
Medicare Part A may cover physical therapy services if a person requires them while staying in a hospital. Medicare also funds physical therapy from Part A if a person receives it in a skilled nursing facility (SNF) following a hospital stay.
Medicare Advantage is a bundled Medicare plan that private insurance companies sell and administer. This plan includes Parts A, B, and, sometimes, Part D, which funds prescription drug cover.
Medicare Advantage plans cover physical therapy in line with Parts A and B. However, some Advantage plans may require a person to use services from physical therapy practices within an agreed network.
A person should contact their insurance company before selecting a physical therapy provider to confirm that they are within the network.
When a person goes to a physical therapy session and expects to pay with Medicare, the physical therapy practice should issue them a notification if it is possible that Medicare will not cover the required physical therapy services.
This practice helps a person minimize unexpected healthcare costs.
Although Medicare covers physical therapy, the services are not completely free. A person must meet their Part B deductible before Medicare funds any outpatient physical therapy. For 2020, the Part B deductible is $198.
Once a person has met this out-of-pocket cost, they will pay 20% of the Medicare-approved amount for physical therapy.
As an example:
- A person’s doctor recommends 10 physical therapy sessions at $100 each.
- The individual has not paid on their Part B deductible for the year.
- They will pay for the first $198 of treatment costs.
- After this, they will pay $160.40 for the remaining block of sessions.
A definitive treatment plan will need to be in place before Medicare will agree to cover a block of physical therapy sessions.
The program will also continually review whether sessions are having the intended effect and whether an individual still requires the therapy. A physical therapist or physician will need to carry out this review and relay the information to Medicare.
The process of creating and maintaining a physical therapy plan may include the following steps:
- A physical therapist evaluates the person who needs physical therapy and creates a plan of care. This plan includes a recommended number of sessions, treatment types, and treatment goals. A physician then approves this plan of care.
- A person uses physical therapy services. During this time, a physical therapist regularly evaluates the person’s progress.
- After the completion of the approved number of visits, a physical therapist and doctor reevaluate the person’s plan. At this time, the therapist may release the individual from further physical therapy. Alternatively, the referring doctor may recommend participating in additional sessions.
- A physical therapist and doctor will continue to reevaluate the plan until a person meets their treatment goals or would no longer benefit from physical therapy.
Treatment progress is not the only consideration when Medicare evaluates continued funding for an individual’s physical therapy.
For example, Medicare requires a physical therapist to recertify that physical therapy is medically necessary after the total costs for therapy exceed $2,080. Medicare calls this a payment threshold.
Here is an example:
- A woman with Medicare was in a car accident and injured her knee.
- Her doctor recommended physical therapy to improve her strength and range of motion.
- She participated in the recommended physical therapy sessions and made improvements in strength but had not fully reached her goals for mobility. Her total physical therapy costs (what she and Medicare had paid) exceeded $2,080.
- She meets with her physical therapist, who agrees that she should continue her therapy sessions to achieve her goals.
- Her physical therapist (and possible her physician, too) approves that continued medical services are necessary through paperwork that they submit to Medicare.
This process confirms the appropriateness of the treatment plan and the medical need for continuing treatment.
Physical therapy is a medical service that optimizes quality of life through prescribed exercise, hands-on care, and patient education. Physical therapists are specially trained healthcare providers who perform physical therapy.
Some of the ways in which physical therapists help a person include:
- instructing people with physically restrictive injuries or illness on what exercises they can perform to strengthen their muscles safely
- performing stretching maneuvers to help a person relieve muscle tension and promote an improved range of motion
- providing hands-on therapy, such as stretching, soft tissue mobilization, or joint mobilization
- using equipment, such as crutches or walkers, that helps either reduce an individual’s pain and discomfort or enhance their mobility
Medicare funds physical therapy for people with certain conditions or in particular circumstances, including:
- arthritis pain and discomfort
- a neurological injury or condition, such as stroke or multiple sclerosis (MS)
- following a surgical procedure, such as a knee or hip replacement
- following an injury
Physical therapists may specialize in certain areas of injury or wellness. For example, some specialize in recovery after orthopedic surgery, while others may focus on sports medicine and recovery after sports injuries.
Physical therapists work in a variety of settings, including:
- rehabilitation centers
- physicians’ offices
- fitness centers
- private practices
Medicare covers medically necessary physical therapy services up to a financial limit. A person may require these services after injury or surgery, or due to underlying medical conditions.
Coinsurances and deductibles apply to physical therapy under Medicare coverage.
If a person is not sure whether Medicare will cover their physical therapy, they should ask their provider before starting their course of treatment.