Observational Therapy
Physical therapy must be deemed medically essential and prescribed by your physician in order for Medicare Part B, which covers outpatient care, to help pay for it. The same is true for speech and occupational therapy.
If being treated as an outpatient, you can receive these services as an outpatient at a number of locations, including a doctor's or therapist's office, a hospital outpatient department, an outpatient rehabilitation facility, skilled nursing facilities, and at home with the help of a therapist associated with a home health agency if you are not qualified for Medicare's home health benefit.
After you've met your Part B deductible ($226 in 2023), Medicare will pay 80% of the Medicare-approved cost for outpatient therapy. Unless you have additional insurance, the remaining 20% will be your responsibility.
But be aware that Medicare will require your provider to certify that therapy is still medically required if your therapy costs exceed $2,230 in a calendar year (2023). Prior to a few years ago, Medicare had annual caps on the amount it would pay for therapeutic outpatient services.
You should also be aware that any therapy suggested by a physical therapist but not prescribed by a physician is not covered. In this instance, the therapist must inform you in writing—through the use of an Advance Beneficiary Notice of Noncoverage, or ABN—that Medicare might not cover the cost of the session. You consent to pay the whole amount if you decide to continue with the therapy.
Intensive Care
After a hospital stay of at least three days, if you need physical therapy at an inpatient rehabilitation facility, such as a skilled nursing facility or at your house, Medicare Part A, which covers hospital treatment, will reimburse the cost.
Your doctor must certify that you have a medical condition that necessitates rehabilitation, ongoing medical supervision, and coordinated treatment provided by your doctors and therapists working together in order for you to be qualified.
The location of the therapy and its duration will determine whether you pay out-of-pocket expenses like deductibles and coinsurance, as well as how much they are. Go to Medicare.gov/coverage/inpatient-rehabilitation-care for further details on out-of-pocket expenses for inpatient therapy.
Coverage under Medicare Advantage
If you are a member of a Medicare Advantage plan, such as an HMO or PPO, these plans are required to provide coverage for both Original Medicare Part A and Part B. However, certain Advantage plans could insist that members only use the services of physical therapy clinics that are part of a predetermined network. Before choosing a physical therapy provider if you have an Advantage plan, you should check with his specific plan to be sure they are in the network.
