Medicare Coverage of Physical Therapy
What It Is
Physical therapy, provided on an outpatient basis
Medicare Part B covers a limited amount of physical 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 be provided by a Medicare-certified therapist.
Medicare Part A or Part B also covers physical 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 physical therapy, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for covered physical therapy provided independently of home healthcare. There's a yearly cap of $1,840 on total Medicare payments for physical therapy (this figure includes any combined speech therapy) provided in any setting other than a hospital outpatient department.
In exceptional circumstances, Medicare Part B may pay more than the yearly cap. But such extra therapy must be preapproved by Medicare based on a special written request submitted by the patient's physician.
If physical therapy is provided in a hospital outpatient department, there's no yearly cap on the total amount Medicare Part B may pay. However, patients may be charged a per-visit co-payment in addition to the 20 percent of the Medicare-approved amount that Medicare doesn't pay.
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 physical 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.