In the first part of our Medicare series, we reviewed the parts of Medicare and talked briefly about Medicare coverage for physical therapy. Now let’s dive into some of the details of Medicare coverage for physical therapy—exactly what’s covered and how much you’ll pay additionally. You’ll remember that Medicare Parts A and B are referred to as “original Medicare,” which is the most commonly used type of Medicare coverage. As of 2018, 66% of Medicare beneficiaries used original Medicare.
Medicare Part A coverage of physical therapy services
Medicare Part A covers the care you receive while you’re in the hospital or a skilled nursing facility as well as any home health care you receive. This often includes physical therapy.
For example, when you have a procedure like a total knee replacement, you’ll likely start physical therapy during your hospital stay, and that physical therapy will be covered under Medicare Part A. The same is true if you receive the post-surgical physical therapy as part of your home health services or your stay at a skilled nursing facility.
Medicare A billing is calculated by the number of days you receive care, not by the services you receive. Each day of care is billed the same, no matter what services you receive on that day. Your physical therapy will be covered as part of the coverage for the day you received the service. How much? The cost per day depends on how many days of care you receive.
● Days 1 through 60: You’ll pay $0. Medicare covers those days 100 percent.
● Days 61 through 90: You’ll pay $352/day, with Medicare covering the rest.
● Starting on day 91: You’ll pay $704/day until you use up what’s known as your “lifetime reserve of days” for that Medicare policy.
The lifetime reserve represents the additional 60 days per year that Medicare will partially fund. Once you hit that number past your initial 90 days, you’ll pay all of your own hospital costs.
Your days are counted in each year. So the first 60 days of hospital, skilled nursing or home health care you receive in each year will be completely covered. Keep in mind that, as with most health insurance plans, you’ll pay a deductible before your coverage kicks in. In 2020, the Part A deductible is $1,408.
Medicare Part B coverage of physical therapy services
Medicare Part B covers your everyday medical care, including outpatient physical therapy. Part B can help cover both physical therapy appointments and physical therapy equipment.
Medicare will pay for all physical therapy appointments that are considered “medically necessary.” This generally means the PT must be part of your treatment for a condition to be covered. However, your physical therapy can also be considered medically necessary if it’s being used to prevent deterioration or maintain your current level of function. The goals for physical therapy that Medicare will typically pay include:
● Pain management
● Stroke recovery
● Surgery recovery
● Injury recovery
● Treatment of chronic conditions like Parkinson’s disease
Medicare coverage of physical therapy doesn’t limit the amount of PT you can receive in a year. You can get as many therapy sessions as you need, as long as the therapy is medically necessary.
As with Part A, you’ll pay a deductible and be responsible for some additional out-of-pocket costs. In 2020, the Part B deductible is $198. You’ll also be responsible for a copayment of 20% of the total Medicare-approved cost of your physical therapy appointments, with Medicare covering the remaining 80 percent.
The PT equipment coverage includes assistive devices like canes or walkers as well as equipment to help you at home, such as raised chair cushions. Part B will cover 80 percent of the Medicare-approved cost of any equipment you need, and you’ll pay the remaining 20 percent.
Medicare coverage cheat sheet
In short, you can use original Medicare to get coverage for physical therapy in both inpatient and outpatient settings. Your out-of-pocket cost will change depending on whether your services fall under Part A or Part B. As a rule, think of all inpatient services as being Part A and all outpatient services as Part B.
What happens when you use Medicare Part C? What about Part D or Medigap? Check back for Part 3 of our Medicare series, when we’ll tackle that!