One of the most commons question related to Medicare is whether it covers physical therapy. Of course, you have heard of Medicare physical therapy “cap”. This is basically Medicare Part B that helps pay for necessary medical services up to a certain limit or “cap”.
By definition, physical therapy involves examination, evaluation, and treatment to improve your ability to move or restore certain aspects of your physical well-being. Physicians sometimes order physical therapy after surgery to help a patient recover and regain mobility. However, the physician may order these services in other situations where physical therapy services might improve your ability to function.
Physical Therapy: Where will you receive the services?
If you were able to receive physical therapy services as part of Medicare-covered home health care, this means that Medicare Part B may cover the full cost of the therapy. Typically, these covered services are part-time or only received occasionally.
If the doctor assigned by Medicare decides that physical therapy is needed outside of home health care, then Medicare Part B will be covering up to 80% of the approved costs of outpatient therapy, speech language pathology, and occupational therapy until the limits are reached. The Medicare Part B deductible is also applicable.
Medicare Physical Therapy Caps
The Medicare limits on these services are called as “therapy cap limits”. This simply means that that Medicare will only be covering up to these limits as described below.
The therapy cap limits for the year 2016 are as follows:
- Physical therapy services and speech-language pathology services combined – $1,960
- Occupational therapy – $1,960
If in case you reach your therapy cap limits and the assigned physician recommends that you continue with the treatment, you can ask your therapist for an exception. This will allow your Medicare to continue paying for your therapy. In addition, the therapist also need to provide proper documentation that these services are medically reasonable and necessary, including those types of services after the therapy cap limit has been reached.
In some instances, you might want to get physical therapy even if it is not considered “medically reasonable and necessary” by Medicare. However, it is important to bear in mind that when physical therapy is not medically reasonable and necessary, your therapist is required to give you a written document called an “Advance Beneficiary Notice of Noncoverage” (ABN). When this happens, Medicare Part B will not be paying for these services, but the ABN will let you decide whether to get them. If you want to get physical therapy, the ABN requests your agreement to pay since Medicare will not cover types of services that are not medically necessary.
Moreover, you may have the option of signing up for a Medicare Supplement (Medigap) plan. This will help you pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as coinsurance, copayments, and deductibles. This is also why it is very important to know the scope and limitations of your current Medicare plan.