This is the third and final installment of our series on Medicare coverage for physical therapy. Previously, our Medicare Part 1 provided an overview of Medicare. Medicare Part 2 explained how to obtain physical therapy coverage through Medicare Parts A and B, also called “original Medicare.” To follow up, this installment explores opportunities to obtain Medicare coverage outside of those provided through original Medicare.
The use of additional parts of Medicare is growing. As of 2019, 22 million Medicare members had a Medicare Advantage plan. A 2017 report found that 13.5 million Medicare members had a Medigap plan.
Medicare Advantage and physical therapy
Medicare Advantage, also called Medicare Part C, is an option that takes the place of original Medicare. All Medicare Advantage plans are required to cover everything that original Medicare does. The difference, however, often is that coverage through a Medicare Advantage plan can go beyond original Medicare. These plans might include added physical therapy allowances or even transportation to and from your physical therapy appointments. Every Medicare Advantage plan has its own features. So if you have a Medicare Advantage plan, you can check the details of your policy or call your Medicare Advantage company to see what all is included in your physical therapy coverage.
Another difference is the use of networks. Many Medicare Advantage plans are health maintenance organizations (HMOs) or Preferred Provider Organizations (PPOs). Both of these plan types use networks of providers, including physical therapists. If your plan is an HMO, it won’t cover your physical therapy when you use an out-of-network provider. If your plan is a PPO, the out-of-network services will still be covered, but you’ll pay a higher copayment than if the services came from an in-network physical therapist.
The third difference is the cost to you. While original Medicare has set costs, each Medicare Advantage plan has different costs. For example, copayments for visits to specialists like physical therapists range from $20 to $50 in the Denver area depending on the Advantage plan you choose. It’s always a good idea to check with your plan if you’re not sure what your cost for a specific service will be.
Medigap and physical therapy
Medigap plans help you pay for the out-of-pocket costs of original Medicare like deductibles and copayments. However, they don’t provide additional coverage. A Medigap plan could come in handy if you need physical therapy. As discussed in Part 2 of our Medicare series, even with Medicare you’ll pay 20% of the cost for your physical therapy appointments and any equipment you might need at home. A Medigap plan can help pay those costs.
The way Medigap works is that you pay a monthly premium to your Medigap plan provider, and your plan will then pay that 20% coinsurance cost. This could save you money if you think you’ll need multiple physical therapy sessions.
Your cost for a Medigap plan will vary depending on the plan you buy and factors such as your age, gender and overall health. Premiums for plans in the Denver area range from as little as $32 to as high as $1,156.
Medicare Part D and physical therapy
Medicare Part D is prescription drug coverage. It doesn’t cover any other services. Your Part D plan can help you cover the costs of medications you might take for the same conditions your physical therapist is addressing. It won’t cover the physical therapy appointments.
Medicare can help you pay for your physical therapy in a number of ways. Original Medicare provides some coverage, or you can use a Medicare Advantage plan to get coverage for the same physical therapy services original Medicare provides but possibly at a lower out-of-pocket cost to you. A Medigap plan can help you cover the cost of physical therapy by covering your 20% coinsurance cost. Medicare Part D can help cover your medications.