Does Medicare cover physical therapy? Yes, and you might be eligible for more services, too

GettyImages 1501185787 e1714075314859

“Physical therapists are movement experts,” says Roger Herr, American Physical Therapy Association (APTA) president. They’re especially important to older adults given that about half of physical therapists’ patients are over the age of 65—and that number is expected to grow as the population ages. 

As part of their scope of practice, physical therapists provide evaluation, consultation, education, and treatment to improve balance, mobility, strength and endurance, coordination, and flexibility, says Herr.

Common conditions treated by physical therapy include osteoarthritis, low back pain, and urinary incontinence.

“Physical therapy can also be useful as a preventative measure, such as when you feel shaky on your feet to prevent a fall, or it can assist in your recovery after a fall or surgery,” says Herr.

Medicare coverage of physical therapy services

Whether you’re staying in a facility, such as a hospital or nursing home, or at home, and need physical therapy, Medicare provides coverage to manage a chronic condition, such as multiple sclerosis (MS), treat an injury or illness, or to ensure you can maintain your independence. Although an order or referral is not required under Medicare, a doctor, nurse practitioner, clinical nurse specialist, or physician assistant must certify that the services are medically necessary.

Medicare Part A will fully cover in-patient physical therapy for the first 60 days after a deductible is met, provided skilled nursing and/or rehabilitation services are required daily. After that, co-payments apply.

Outpatient coverage, which includes visits to a physical therapy clinic, or at home for older adults  who are not homebound, is covered by Medicare Part B. After you meet the annual deductible, Medicare pays 80%, and you pay 20% of the Medicare-approved amount.

If you haven’t checked your coverage lately, you might be eligible for more services.

“Physical therapy coverage through Medicare changed in 2018,” says Diane Omdahl, author of Medicare for You and cofounder of the Medicare advisory firm 65 Incorporated.

“Before that, there were coverage limits. The rule changed to unlimited Medicare coverage for medically necessary outpatient physical therapy services each calendar year,” says Omdahl.

Medicare Advantage coverage of physical therapy services

“Medicare Advantage plans may require prior authorization before approving your physical therapy treatment,” says Herr. Your physical therapist may need to perform an evaluation and submit a treatment plan to get approval for coverage, Herr explains.

Once approved, Medicare Advantage plans offer the same coverage as Medicare Parts A and B, with a few exceptions. Medicare Advantage plans may have different deductibles, require members to use physical therapy services from their networks and/or conduct more frequent audits or reviews to minimize costs and reduce over-utilization of services, says Herr.

Medicaid coverage of physical therapy services

Medicaid coverage of physical therapy services is an optional benefit depending on your state, so you’ll need to check to see what benefits your state offers.

Coverage of occupational therapy and speech-language pathology

In addition to physical therapy, Medicare, Medicare Advantage, and Medicaid generally provide the same coverage for other rehabilitation therapies as long as they are deemed medically necessary, says Herr.

This includes occupational therapy, or assistance helping you perform activities of daily living  (such as bathing or dressing), home management, and community re-entry to maintain current capabilities or slow decline.

It also includes speech-language pathology, which offers support for help with speech and language skills, swallowing, and cognitive skills to maintain or improve current function or slow decline.

Outpatient physical therapy in a facility or at home—which is better?

All outpatient therapy is covered by Medicare Part B, but you may wonder if getting physical therapy at home is as useful as that provided at a facility.

“Physical therapy locations may have additional equipment and resources than what a physical therapist can provide in the home,” says Herr.

In addition, Herr says that the wait for physical therapy services at a facility may be less than those provided in the home.

“Going out to get physical therapy also helps with socialization, which may have been hindered when dealing with a mobility issue,” says Herr.

For some patients, however, home-based outpatient therapy provides an opportunity to address environmental challenges in the home and ensure that an individual can manage safely and independently in their own setting. Home-based therapy also serves to improve access to therapy for those without reliable transportation, says Herr.

Difficulty finding physical therapists

Even though Medicare covers physical therapy, it may be hard to find a physical therapist.

“The physical therapy shortage peaked during the pandemic, but we’re still seeing double-digit vacancies,” says Herr.

Other factors continue to contribute to the ongoing shortage, according to a KFF news report. One is that physical therapists are now required to have doctorates, so fewer students are entering the field. Another is that Medicare has cut physical therapy reimbursements by 9%  over the last four years, which has led to lower staffing levels. 

Source link

About The Author

Scroll to Top