Physical therapy is essential for individuals recovering from injuries, surgeries, or managing chronic conditions, aiming to restore mobility, strength, and overall function. In the United States, Medicare and Medicaid provide coverage for these services, though the extent and specifics of coverage vary based on the program and individual circumstances.
Medicare coverage for physical therapy
Medicare Part A: Inpatient services
Medicare Part A covers inpatient physical therapy received during hospital stays or in skilled nursing facilities (SNFs). Coverage is provided if the therapy is deemed medically necessary for recovery. After meeting the Part A deductible, Medicare fully covers the first 60 days of inpatient care. Beyond this period, coinsurance payments apply. For instance, in 2024, the deductible is $1,632 per benefit period, with daily coinsurance costs of $400 for days 61-90.
Medicare Part B: Outpatient services
Medicare Part B covers outpatient physical therapy, including services provided in clinics, private practices, and at home for eligible individuals. After meeting the annual deductible ($240 in 2024), Medicare covers 80% of the approved amount for therapy services, leaving beneficiaries responsible for the remaining 20%. Notably, there is no longer a cap on the number of therapy sessions covered per year, provided they are medically necessary.
Medicare Advantage (Part C)
Medicare Advantage plans, offered by private insurers, are required to provide at least the same level of coverage as Original Medicare (Parts A and B). However, these plans may have different deductibles, copayments, and network restrictions. Some may require prior authorization for physical therapy services. It’s essential for beneficiaries to review their specific plan details to understand coverage and any additional requirements.
Medicaid coverage for physical therapy
Medicaid, a state-administered program for low-income individuals, offers varying coverage for physical therapy services. While federal guidelines provide a framework, each state determines its own coverage policies, eligibility criteria, and payment rates. Some states may offer comprehensive physical therapy benefits, while others might have limitations or require prior authorization. For example, in certain states, recipients 20 years of age or younger and not in a long-term care plan may receive physical therapy services under specific coverage and limitations policies.
Eligibility and accessing services
To qualify for Medicare-covered physical therapy, a healthcare provider must certify that the services are medically necessary. For outpatient therapy under Part B, no prior hospitalization is required. In contrast, Medicaid eligibility and coverage specifics depend on state regulations, income levels, and medical necessity. Beneficiaries should consult their state’s Medicaid program for detailed information.
Considerations for beneficiaries
- Provider acceptance: Not all physical therapists accept Medicare or Medicaid. It’s crucial to confirm that a chosen provider is enrolled in the respective program to ensure coverage.
- Prior authorization: Some Medicare Advantage and Medicaid plans may require prior authorization for physical therapy services. Beneficiaries should verify any such requirements with their plan administrators.
- Cost sharing: Even with coverage, beneficiaries may be responsible for deductibles, coinsurance, or copayments. Understanding these potential out-of-pocket costs is essential for financial planning.
