How Many Days Will Medicare Pay For Physical Therapy?

Vincent Thrasher

Founder at - over65 insurance options

Vincent Thrasher, the pioneering founder of Over65InsuranceOptions, has an impressive 20-year tenure in the insurance industry. His in-depth expertise spans the entire spectrum of senior...Read more

Physical therapy is a crucial component of the healthcare system, helping patients recover from injuries and illnesses. However, many patients are unsure of how long they can receive Medicare coverage for this treatment. This is an important concern, as physical therapy can be costly without insurance coverage. If you’re wondering how many days Medicare will pay for physical therapy, read on to learn more.

How Many Days Will Medicare Pay for Physical Therapy?

Physical therapy is an essential aspect of healthcare for many individuals who need to recover from injuries or manage chronic conditions. Medicare, the federal health insurance program for people aged 65 or older, covers physical therapy services for beneficiaries who meet certain criteria. But how many days will Medicare pay for physical therapy? Let’s explore the details.

Medicare Coverage for Physical Therapy

Medicare covers physical therapy services under its Part B benefits, which include outpatient services. To qualify for Medicare coverage for physical therapy, the beneficiary must have a doctor’s order or referral for the services, and the services must be medically necessary and provided by a licensed physical therapist or other qualified healthcare professional.

Under Medicare, there is no limit on the number of physical therapy sessions that a beneficiary can receive. However, there are limits on the amount of payment that Medicare will make for such services. In general, Medicare pays 80% of the Medicare-approved amount for physical therapy services, and the beneficiary is responsible for the remaining 20% as coinsurance.

Medicare Part B Deductible and Coinsurance

In addition to the coinsurance, Medicare beneficiaries must also meet their Part B deductible before Medicare will begin paying for physical therapy services. The Part B deductible for 2021 is $203, which means that the beneficiary must pay that amount out of pocket before Medicare will start paying for services.

Once the deductible is met, Medicare will pay 80% of the Medicare-approved amount for physical therapy services, and the beneficiary will be responsible for the remaining 20% coinsurance. It’s worth noting that some Medicare Advantage plans may offer different cost-sharing arrangements for physical therapy services.

Medicare Coverage Limits for Physical Therapy

Although there is no limit on the number of physical therapy sessions that a Medicare beneficiary can receive, there are limits on the amount of payment that Medicare will make for such services. In 2021, the Medicare therapy cap is $2,110 for physical therapy and speech-language pathology services combined.

Once the beneficiary reaches the therapy cap, Medicare will stop paying for physical therapy services unless the beneficiary qualifies for an exception. One exception is the KX modifier, which allows the beneficiary to continue receiving therapy services if the therapist certifies that the services are medically necessary.

Medicare Exceptions for Physical Therapy Coverage

Another exception to the therapy cap is the targeted medical review process, which applies to beneficiaries who exceed $3,000 in therapy services in a calendar year. Under this process, Medicare may review the beneficiary’s medical records to determine if the therapy services are medically necessary and appropriate.

In addition, there is no therapy cap for beneficiaries who receive services in a hospital outpatient department or a critical access hospital. However, the beneficiary must still meet the requirements for medical necessity and receive the services from a licensed physical therapist or other qualified healthcare professional.

Benefits of Physical Therapy for Medicare Beneficiaries

Physical therapy can provide a range of benefits for Medicare beneficiaries who need to manage pain, improve mobility, or recover from an injury or illness. Physical therapy can help beneficiaries:

• Reduce pain and inflammation
• Improve strength and flexibility
• Restore mobility and range of motion
• Prevent falls and injuries
• Manage chronic conditions like arthritis and diabetes

In addition, physical therapy can help beneficiaries avoid more invasive treatments like surgery or medication. By providing personalized care and guidance, physical therapists can help beneficiaries achieve their health and wellness goals and improve their quality of life.

Physical Therapy vs. Occupational Therapy

It’s worth noting that physical therapy is not the same as occupational therapy, which focuses on helping people perform daily activities and tasks. While both types of therapy can be valuable for Medicare beneficiaries, they are distinct services with different goals and approaches.

Physical therapy focuses on restoring physical function, while occupational therapy focuses on improving functional independence and quality of life. Beneficiaries may receive both types of therapy, depending on their needs and goals.

Conclusion

Medicare provides coverage for physical therapy services for beneficiaries who meet certain criteria, including having a doctor’s order or referral for the services and receiving the services from a licensed physical therapist or other qualified healthcare professional. While there is no limit on the number of physical therapy sessions that a beneficiary can receive, there are limits on the amount of payment that Medicare will make for such services. Beneficiaries should work with their healthcare provider and physical therapist to determine the best course of treatment and to ensure that the services they receive are medically necessary and appropriate.

Frequently Asked Questions

Physical therapy is an essential part of healthcare for many individuals, especially seniors. Medicare is a federal program that provides health insurance to those aged 65 and older, as well as those with certain disabilities. It covers a variety of healthcare services, including physical therapy. Here are some common questions and answers about how many days Medicare will pay for physical therapy.

1. How many days of physical therapy will Medicare cover?

Medicare will cover physical therapy as long as it is deemed medically necessary. The number of days that Medicare will pay for physical therapy varies depending on the individual’s needs and condition. In general, Medicare will cover up to 100 days of physical therapy per benefit period. However, this coverage is subject to certain limitations and requirements.

It’s important to note that Medicare will only cover physical therapy that is provided by a licensed healthcare professional. The therapy must also be ordered by a doctor and provided by a Medicare-approved provider. If the individual requires additional therapy beyond what Medicare will cover, they may need to pay out-of-pocket or seek coverage from a private insurance plan.

2. What are the limitations on Medicare coverage for physical therapy?

While Medicare will cover physical therapy up to 100 days per benefit period, there are some limitations on this coverage. For example, Medicare will only cover physical therapy that is deemed medically necessary and that is aimed at improving the individual’s condition or preventing further decline. If the therapy is not deemed medically necessary, Medicare may not cover it.

In addition, Medicare will only cover physical therapy that is provided by a licensed healthcare professional. This includes physical therapists, occupational therapists, and speech-language pathologists. The therapy must also be ordered by a doctor and provided by a Medicare-approved provider. If any of these requirements are not met, Medicare may not cover the therapy.

3. What happens if an individual needs more than 100 days of physical therapy?

If an individual needs more than 100 days of physical therapy in a benefit period, they may be able to receive additional coverage under certain circumstances. However, this additional coverage is subject to certain requirements and limitations.

For example, the individual must demonstrate that they continue to require physical therapy and that they are making progress towards their goals. They must also have a plan of care that outlines their therapy needs and goals. If these requirements are met, Medicare may provide additional coverage for physical therapy beyond the initial 100 days.

4. What is the cost of physical therapy under Medicare?

The cost of physical therapy under Medicare varies depending on the individual’s coverage and the provider they use. In general, Medicare will cover 80% of the cost of physical therapy, and the individual is responsible for the remaining 20%. However, if the individual has a Medicare Advantage plan or other private insurance, the cost may be different.

It’s important for individuals to check with their provider to understand their specific costs for physical therapy under Medicare. In some cases, the individual may be able to receive physical therapy at no cost if they meet certain requirements.

5. How can an individual find a Medicare-approved provider for physical therapy?

To receive coverage for physical therapy under Medicare, the therapy must be provided by a Medicare-approved provider. This includes physical therapists, occupational therapists, and speech-language pathologists. The individual can find a Medicare-approved provider by using the Medicare Provider Directory on the Medicare website.

The individual can search for providers by location, specialty, and other criteria. They can also contact their doctor or healthcare provider for recommendations. It’s important to ensure that the provider is Medicare-approved before receiving physical therapy, as Medicare may not cover therapy provided by an unapproved provider.

In conclusion, Medicare will pay for physical therapy services for as long as the patient needs them. However, this coverage is subject to certain limitations and rules that patients and providers must follow. It is important for patients to understand their Medicare coverage and work closely with their healthcare providers to ensure they receive the necessary care.

If a patient reaches their therapy cap limit, they may still be able to receive additional services through an exception process. This process requires the therapist to provide documentation that justifies the medical necessity of continued therapy. Patients should discuss their options with their healthcare provider and Medicare to determine their best course of action.

In summary, while there are limitations to Medicare coverage for physical therapy, patients can rest assured that they can receive the care they need for as long as necessary. By staying informed and working closely with their healthcare providers, patients can navigate the Medicare system and receive the best possible care.

Vincent ThrasherFounder at - over65 insurance options

Vincent Thrasher, the pioneering founder of Over65InsuranceOptions, has an impressive 20-year tenure in the insurance industry. His in-depth expertise spans the entire spectrum of senior insurance, encompassing Medicare, Medigap, long-term care insurance, life insurance, and dental, vision, and hearing insurance. Vincent's unwavering passion for guiding seniors through the intricate insurance landscape and crafting customized solutions to address their individual needs has earned Over65InsuranceOptions an esteemed reputation as a dependable ally for seniors nationwide.

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