Savvy Living

Can you explain how Medicare covers physical therapy services? I'm a new beneficiary and would like to get some treatments for my back.

Medicare covers a variety of outpatient therapy services, including physical, occupational and speech therapy. In order to receive coverage, you must meet certain criteria. Here's how it works.

Medicare Coverage

In order for Medicare (Part B) to help cover your physical therapy, the therapy must be considered medically reasonable and necessary and will need to be ordered or prescribed by your doctor.

Medicare will cover services that are performed at outpatient facilities, including doctors' offices, therapists' offices, rehabilitation facilities, medical clinics and hospital outpatient departments.

You also need to know that Medicare limits the amount of coverage that it will provide for outpatient therapy services in one calendar year. These limits are called "therapy cap limits." In 2017, Medicare will cover up to $1,980 for physical and speech therapy combined and another $1,980 for occupational therapy.

Be aware that just like other Medicare covered services, Medicare will pay 80% (up to $1,584) of your therapy costs after you meet your $183 Part B deductible. You, or your Medicare supplemental plan (if you have one), will be responsible for the remaining 20% until the cap limits are reached. After that, you'll have to pay the full cost for the services.

Extra Therapy

If, however, you reach your cap limits and your doctor or therapist recommends that you continue with the treatment, you can ask your therapist to provide documentation so that you can receive an exception that will enable Medicare to continue to pay for your therapy. The therapist must provide documentation indicating that these services are medically necessary for you to continue. If Medicare denies the claim, you can appeal through the Medicare appeals process (see Medicare.gov/claims-and-appeals).

If approved, Medicare has an exception threshold of $3,700 for physical and speech therapy combined and $3,700 for occupational therapy. If your therapy cost exceeds these thresholds, Medicare will audit your case, which could lead to denial of further services.

No Coverage

If you choose to receive physical therapy that's not considered medically necessary or prescribed by your doctor, your therapist is required to give you a written document called an "Advance Beneficiary Notice of Noncoverage" (ABN). Medicare Part B will not pay for these services.

Therapy at Home

You should also know that Medicare covers home therapy services too. In order to receive these services, you must be homebound and eligible to receive home health care from a Medicare-approved home healthcare agency. To learn more about this option, see the "Medicare and Home Health Care" online booklet at Medicare.gov/pubs/pdf/10969.pdf.

Medicare Advantage

If you are enrolled in a Medicare Advantage plan (like an HMO or PPO), these plans must cover everything that's included in original Medicare Part A and Part B coverage. Sometimes these plans cover more, with extra services or an expanded amount of coverage. To find out whether your plan provides extra coverage or requires different co-payments for physical therapy, you'll need to contact the plan directly.

More Information

If you have other questions, call Medicare at 800-633-4227 or contact your State Health Insurance Assistance Program (SHIP), which provides free Medicare counseling in person or over the phone. To find a local SHIP counselor visit Shiptacenter.org, or call the eldercare locator at 800-677-1116.

Savvy Living is written by Jim Miller, a regular contributor to the NBC Today Show and author of "The Savvy Living” book. Any links in this article are offered as a service and there is no endorsement of any product. These articles are offered as a helpful and informative service to our friends and may not always reflect this organization’s official position on some topics. Jim invites you to send your senior questions to: Savvy Living, P.O. Box 5443, Norman, OK 73070.