Are you looking for medicare physical therapy coverage? Okay, let’s jump into the article. We will help you to find the right plan that fits YOU!

Over the years, getting the best quality of health services has been a priority, and although physicians have stopped at nothing in giving individuals the best possible healthcare services, healthcare is never too much or even enough.

With health insurance plans available, individuals have been able to access quality healthcare without much fuss, still, certain benefits may be omitted. When it comes to healthcare and health insurance, efficiency and affordability always come into play and the question of “Can I get this specific service from this plan?” is often asked.

Well, healthcare, as well as healthcare insurance, is evolving exponentially hence, it can only get better. In recent times, eligible individuals seem to have found solace in Medicare plans even though these plans might offer limited coverage.

This has been achieved either by supplementing Original Medicare plans, looking for an additional plan, or settling for the services offered by Medicare.

Do not get me wrong, Medicare offers one of the best health insurance policies yet it has certain limitations as does every health insurance plan; it sometimes offers lesser health insurance coverage than we need sometimes. And although Medicare will cover “necessary” health needs, sometimes we just want more.

One of these health needs that are not so common but greatly important is physical therapy. Although it is often underrated and its efficiency not fully understood, physical therapy is a necessary routine for individuals of all ages.

Its importance is innumerable, according to a statement released by the American Physical Therapy Association, the importance of physical therapy includes restoration of the normal physical function of an individual, prevention of disabilities, and impairments.

Also, physical therapy is said to prevent movement restrictions as well as structural and functional limitations that might arise from accidents, diseases, and injuries from other conditions.

Based on an article released in 2022, physical therapy is said to be a form of medical care that helps to treat injuries or diseases that alter body function by the use of physical analysis, exercise, or even chiropractic care. This form of health service is said to be one of the most effective forms of treating individuals with injuries and disabilities.

With physical therapy, individuals with altered postures due to accidents or injuries would learn to walk again, and those with difficulty standing would also be helped to stand better.

This method has helped so many lives and so individuals always strive to ensure that physical therapy coverage is part of their health plan. This is a really good way to go about it, even though sometimes you might not get physical therapy coverage based on your health insurance company policy or specific health plan.

Oftentimes, people ask if Medicare offers coverage for physical therapy, it is a logical question especially when you consider the conservative nature of Medicare coverage. Well, the truth is that Medicare generally provides care for medically important services.

Medicare would not cover any health expense that is deemed unnecessary, aesthetic, or medically inefficient. However, physical therapy is a very important medical routine with so many health advantages.

Contrary to certain opinions, physical therapy is a medical necessity and every individual should have at least one form of physical therapy or the other. Hence, it is quite easy to get a physical therapy coverage plan through a viable health insurance policy even though the coverage would depend on the specific health insurance plan you are on.

That is why Medicare offers physical therapy coverage to beneficiaries to treat various conditions and prevent others from arising.

It is, however, important that you note the fact that Medicare would only pay for physical therapy that is deemed “medically necessary” either to treat or prevent an illness, any other form of therapy would have to be paid for by you.


About Medicare Physical Therapy Cap 2022

There are various types and classes of Medicare plans that one can get while seeking medicare health insurance coverage that gives good physical therapy.

Health insurance company providers have taken the necessary measures to ensure that affordable Medicare plans are available to citizens and residents in the United States as far as the minimum eligibility requirements and criteria are met by the individual applying for the healthcare insurance plan.

Some of the most popular and efficient Medicare plans include the Medicare Part A and Part B plans, the Medicare Supplement plans, and the Medicare Advantage plans. Let’s briefly look into some of these top Medicare plans we have available in the country.


Medicare Part A

A typical Medicare plan will provide coverage services as part of the plan package to just certain aspects of the individual’s health – and that’s the aspects that are considered necessary and reasonable.

So, for physical therapy-related coverage, you can get some sort of coverage from Medicare Part A plans and policies.

These physical therapy services offered by the Medicare Part A plan will most likely help insure against excessive expenses on at-home services or inpatient costs – good examples of which are high-quality-quality nursing centers and rehabilitation equipment and facilities.


Medicare Part B

There’s also the Medicare Part B plan coverage, with which you can get premium physical therapy coverage and health services needed. The medical services required are to be certified and recommended by a health practitioner like a physical therapist or qualified physician.

Just like Medicare Part A, the aspect of the Medicare Part B that covers physical therapy is most likely going to help insure against excessive expenses on at-home services or inpatient costs like the high-quality nursing centers and rehabilitation equipment and facilities.

The Medicare Part B plan coverage would involve physical therapy, occupational therapy, and outpatient therapy among some other types of therapy. These methods should help prevent, cure or reduce to a bare minimum the unhealthy conditions of the patient or individual.


Medicare Advantage

Medicare Advantage too can serve to provide health coverage for the expenses associated with physical therapy.

One of the requirements needed though is that the deductibles on the Medicare Part B plans are met and then up to four-fifths of for-fifths the total costs for physical therapy would be covered by the Medicare Advantage plan. That’s about 80% of the whole expenses.

Also, this coverage from the Medicare Advantage plan would only be up when physical therapy is required and deemed medically essential. For more check on Medicare Advantage vs. Medicare Supplement plans.


Medicare Supplement (Medigap)

There are certain aspects of physical therapy that a Medicare Part A plan or Medicare Part B plan would likely not cover. At these points, the Medicare Supplement plans also called Medigap can come into play.

To help with the gulf, Medigap or Medicare Supplement come in to cover the gap. And this involves the 20% cost of coinsurance and related expenses like the deductibles from a Medicare Part B plan.


medicare physical therapy


What are the Medicare physical therapy guidelines for 2022?

Not too long ago, over  62 million Americans were beneficiaries of Medicare plans. With the aging population and activity levels of older adults, more and more Medicare patients are seeking physical therapy services.

With CMS  leading the insurance industry with documentation and billing standards it is p physical therapists must understand and outs Medicare physical therapy guidelines to receive reimbursement for their services.

Billing for physical therapy is generally based on the guidelines and reimbursement rates set by third-party payers. However, physical therapy billing guidelines for medicare patients are based on the  8-minute rule.

Physical therapists must provide a minimum of  8  minutes of time-based physical therapy service to be able to bill for it. 

Billing errors and mistakes can be costly and time-consuming for physical therapy practices and you must understand what the 8-minute rule is and how it relates to the physical therapy services that you provide.

To bill one unit of time for a code, the provider must spend at least  8  minutes performing the service.

To calculate the number of units to bill for timed codes,  add up the total minutes spent and divide by 15. This will give you the number of units you can bill.

So how do we calculate how many units to bill for while co-lying with medicare physical therapy billing guidelines?

Below is an easy-to-use 8-Minute Rule  table that separates time spent on a  physical  therapy  service and the  associated  number of  units  that could be billed:

  • 8-22 mins: 1 unit
  • 23-37 mins: 2 units
  • 38- 52 mins:  3 units
  • 53- 67 mins:  4 units

So for example,  if you spent 15  minutes on therapeutic exercise and 15  minutes on gait training that would be a total of 30mins or 2  units (1 unit of therapeutic exercise and 1 unit of gait training).

In the past, Medicare imposed an annual limit, or cap, on the number of therapy services you could get in any calendar year. The costs for physical therapy, occupational therapy, and speech-language pathology all contributed to your annual therapy cap.

If you continue to get physical therapy or other therapy services beyond this amount, your claim may be reviewed by Medicare once the amount reaches $3,000 for either physical therapy and speech-language pathology, or occupational therapy.

If Medicare determines that your doctor hasn’t provided enough information to justify continued therapy, Medicare may decide not to cover any additional services.

If this happens, your health care provider or physical therapist must give you a  notice explaining that Medicare may not cover additional services that aren’t considered medically necessary for your treatment.

This notice is called an Advance Beneficiary Notice of Noncoverage (ABN). If you get an ABN  from your provider,  you can either end your physical therapy or continue with your treatments, understanding that you agree to pay for them yourself.


Overall Verdict

Your doctor may prescribe Medicare physical therapy for many different reasons. According to the American Physical Therapy Association,  physical therapists help restore normal physical function and help prevent impairments, disabilities, and functional limitations resulting from injuries,  diseases, and other conditions.

Physical therapy is care that evaluates and treats injuries or diseases that change your ability to function and helps to improve or maintain current function that may be declining.

If you need physical therapy and you’re wondering what your Medicare physical therapy costs are,  this article will help you understand your coverage.


Frequently Asked Questions

Does Medicare pay for physical therapy?

Yes. Medicare covers physical therapy that’s considered medically necessary to treat an injury or illness,  such as to manage a  chronic condition like Parkinson’s disease or aid recovery from a fall, stroke or surgery.

Medicare covers occupational therapy, which helps with daily living activities,  such as bathing, dressing and eating.

The Medicare plans also cover speech-language pathology, which provides evaluation and treatment to regain and strengthen speech and language skills.


Does Medicare cover physical therapy?

Medicare pays for medically necessary physical therapy whether you receive it in a  hospital, a  physical therapy center, or in your home. Medicare enrollees have to work with their therapists, doctors, and sometimes Medicare to ensure coverage.

If you have a Medicare supplement (Medigap) plan,  you will get a  break on your out-of-pocket costs. That’s because all Medigap plans pay at least Part A hospital coinsurance that may apply,  and many pay the deductible as well.

Medicare Advantage (MA) plans pay for inpatient physical therapy,  but you are likely to face coinsurance and copays. Unlike  Original Medicare,  most Medicare Advantage plans to limit which hospital and skilled nursing facilities you can use to those in a network.

You also are likely to need prior authorization. Medicare Advantage plans can make their own coverage rules,  but they can’t be more restrictive than traditional Medicare. They also can’t charge enrollees more out of pocket for skilled nursing facility care.


Which inpatient physical therapy does Medicare cover?

A typical Medicare Part A plan would cover things like inpatient stays in hospitals,  skilled nursing facilities, and some home care,  as well as physical therapy at inpatient rehabilitation facilities. It may also cover in-home services if you’re eligible for home care or services that you receive at a  skilled nursing facility after a three-day hospitalization.

Your out-of-pocket costs,  such as Medicare deductibles and coinsurance, depending on the treatment setting. For example, your share of the cost is different if you receive the care in a hospital compared to a  skilled nursing facility.