Medicare Coverage of Occupational Therapy
What It Is
Occupational therapy, provided on an outpatient basis, to help a patient learn how to safely manage activities of daily life (usually while recovering from an illness, injury, or procedure)
Medicare Part B covers a limited amount of occupational therapy, provided on an outpatient basis in a doctor's or therapist's office, rehabilitation facility, clinic, hospital outpatient department, or patient's home. The therapy must be prescribed and regularly reviewed by a doctor, and it must be provided by a Medicare-certified therapist.
Medicare Part A or Part B also covers occupational therapy as part of comprehensive in-home care provided by a Medicare-approved home healthcare agency.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for occupational therapy, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for covered occupational therapy provided independently of home healthcare. There's a yearly cap of $1,840 on total Medicare payments for occupational therapy provided in any setting other than a hospital outpatient department (there's no yearly limit for therapy at a hospital outpatient department).
Medicare Part A or Part B pays 100 percent of the cost for Medicare-covered in-home care provided by a home healthcare agency (including occupational therapy). There's no yearly limit on the amount Medicare will pay for covered in-home care.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.