Medicare Coverage for Physical Therapy Services
If you have Medicare and need physical therapy, you may be wondering what’s covered and how much you’ll need to pay. Physical therapy can play a crucial role in improving mobility, reducing pain, and enhancing your quality of life, so understanding your benefits is essential.
Does Medicare Cover Physical Therapy?
Yes, Medicare does cover physical therapy services when they are medically necessary. Coverage falls under Medicare Part B, which helps pay for outpatient therapy services, including rehabilitation for injuries, post-surgical recovery, and chronic conditions.
However, it is essential to work with a Medicare-approved provider to ensure your services are covered.
What Does Medicare Part B Cover?
Medicare Part B provides coverage for the following physical therapy services:
Initial evaluation and assessments
Therapeutic exercises and treatments designed to restore movement and function
Manual therapy techniques for pain relief and improved mobility
Neuromuscular re-education to improve balance and coordination
Specialty services such as balance training and fall prevention
These services must be deemed medically necessary and provided by a qualified healthcare professional, such as a licensed physical therapist.
Cost Breakdown for Medicare Patients
Medicare typically covers 80% of the approved cost of physical therapy services after you meet your Part B deductible (which is $240 in 2024). You are responsible for the remaining 20% coinsurance, unless you have supplemental insurance (Medigap) that helps cover the out-of-pocket costs.
Here’s a breakdown of potential costs:
Medicare Part B deductible: $240 (2024)
Medicare covers: 80% of approved costs after deductible
Patient responsibility: 20% coinsurance per visit
Medigap plans: May cover the 20% coinsurance, reducing out-of-pocket costs
If you have a Medicare Advantage Plan, your coverage may vary. Some plans offer additional benefits, such as reduced copays or coverage for specialty services.
Annual Therapy Cap – Is There a Limit?
While Medicare does not have a hard cap on physical therapy visits, they do set a threshold amount each year. In 2024, the therapy cap is $2,330 for combined physical therapy and speech therapy services. If your therapy needs exceed this amount, your provider may need to confirm continued medical necessity for additional visits.
If you require ongoing therapy, your provider will document your progress and submit a request for continued coverage to Medicare.
Do You Need a Referral for Medicare to Cover Physical Therapy?
Medicare requires that physical therapy services be medically necessary and prescribed by a doctor, nurse practitioner, or physician assistant. However, you do not need a referral to begin treatment. Instead, you need a diagnosis and documented need for therapy before services are approved.
What If Medicare Doesn’t Cover Everything?
If Medicare does not cover the full cost of your therapy, here are some options to help manage expenses:
Medicare Supplement (Medigap) Plans – These plans help cover Medicare’s out-of-pocket costs, such as copays and coinsurance.
Medicare Advantage Plans – Some Medicare Advantage plans offer additional benefits beyond Original Medicare, but coverage varies.
Self-Pay Options – Some clinics offer discounted rates for Medicare patients paying out-of-pocket.
HSAs or FSAs – If you have funds saved in a Health Savings Account (HSA) from a previous employer, you may use them to cover costs.
Maximizing Your Medicare Benefits for Physical Therapy
To make the most of your Medicare coverage, follow these tips:
✔ Verify your benefits before starting treatment to understand potential costs.
✔ Ask about supplemental coverage if you have a Medigap or Medicare Advantage plan.
✔ Work with a Medicare-approved provider to ensure services are covered.
✔ Keep track of your visits to avoid exceeding annual limits and ensure continued coverage.
✔ Communicate with your therapist about your progress and any concerns about costs.
Get Reactive! Get the Care You Need in Cache Valley
If you need physical therapy in Providence or North Logan and have Medicare, we can help you understand your benefits and out-of-pocket costs.
Call us at (435) 535-3677 (Providence) / (435) 213-9268 (North Logan) or schedule an appointment online today! Let’s get you on the path to recovery while maximizing your Medicare benefits.