Medicare Coverage of Physical Therapy

Last Updated : 09/10/20183 min read

One of the questions beneficiaries ask is whether Medicare covers physical therapy. You may have heard about the Medicare physical therapy “cap.” Medicare Part B helps pay for medically necessary services, generally up to a certain limit or cap as described below.

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Physical therapy involves examination, evaluation, and treatment to improve your ability to move or restore certain aspects of your physical well-being, according to the Mayo Clinic. Doctors sometimes order physical therapy after surgery to help you recover and regain your mobility, but might order these services in other situations where physical therapy services might improve your ability to function.

Where will you receive physical therapy services?

If you receive physical therapy services as part of Medicare-covered home health care, Medicare Part B may cover the full cost of the therapy. Typically these covered services are part-time or only received occasionally.

If your Medicare-assigned doctor decides that physical therapy is medically necessary outside of home health care, Medicare Part B will cover 80 percent of the Medicare-approved costs of outpatient physical therapy, occupational therapy, and speech-language pathology, until the limits are reached. The Medicare Part B deductible also applies.

What are Medicare physical therapy caps?

Medicare limits on these services are called “therapy cap limits” – meaning simply that Medicare will only cover up to these limits as described below. The therapy cap limits for 2016 are as follows:

  • Physical therapy services and speech-language pathology services combined – $1,960
  • Occupational therapy – $1,960

If you reach your therapy cap limits and your doctor recommends that you continue with the treatment, you can ask your therapist for an exception so that Medicare will continue to pay for your therapy. The therapist must provide documentation that these services are medically reasonable and necessary, including services after the therapy cap limit is reached.

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In some situations, you might want to get physical therapy even if it’s not considered “medically reasonable and necessary” by Medicare. Before you get physical therapy that’s not medically reasonable and necessary, your therapist is required to give you a written document called an “Advance Beneficiary Notice of Noncoverage” (ABN). Medicare Part B won’t pay for these services, but the ABN lets you decide whether to get them. If you decide to get physical therapy, the ABN requests your agreement to pay since Medicare will not cover services that are not medically necessary.

You may have the option of signing up for a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

We’ll be happy to fill you in on more details about Medigap, as well as Medicare Advantage or Medicare prescription drug plans.

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This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

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