Can my mother continue to see her current physical therapist if she isn't Medicare certified?

1 answer | Last updated: Nov 24, 2016
A fellow caregiver asked...

My mother just got Medicare, and we found out her current physical therapist isn't Medicare certified. Can my mother still go to her for therapy?

Expert Answers

The question is not really whether your mother can continue to be treated by this physical therapist but whether Medicare will pay for it if she does. Your mother is always free to get treatment from anyone she wants. But if Medicare does not pay for it, she will have to pay for it herself, or with other insurance. The answer to the question of whether Medicare will cover treatment by someone who is not certified by Medicare is, unfortunately, no. One of the basic rules of Medicare is that it will only cover non-emergency treatment provided by a Medicare certified provider.

Even if your mother finds a new physical therapist who is certified by Medicare, however, Medicare will not necessarily cover it any time your mother gets treatment, and even for covered therapy it will pay only up to certain limits. In order for Medicare to pay anything, its rules say that the therapy must be medically necessary and prescribed by a physician. That means your mother can’t just decide to go get therapy on her own, even if the therapist agrees that she needs treatment. She needs to have a physician prescribe the specific physical therapy, and the physician periodically needs to review her continuing need for the therapy if she continues to get it over a prolonged period of time.

There are also rules about how much Medicare will pay for the physical therapy it covers. Once your mother has paid the yearly Part B deductible amount, Medicare Part B pays 80 percent of the amount it approves for therapy; your mother has to pay the remaining 20 percent out of her pocket, unless she has other insurance such as a Medigap policy. And there is a cap on the total amount Medicare will pay in a year for physical therapy; in 2008 it is $1,810. To learn more about the rules of Medicare coverage for physical therapy, take a look at the official Medicare publication Medicare Limits on Therapy Services.