Medicare Coverage Limits For Physical Therapy | MedicarePlanFinder

Navigating the Medicare Physical Therapy Cap

Anastasia Iliou Fitness & Health, Medicare

Medicare can help pay for physical therapy, which may be a crucial part of injury or surgery recovery. However, Medicare’s coverage has limits.

Every Medicare beneficiary begins with Original Medicare, which includes Part A, hospital coverage, and Part B, medical coverage. Most physical therapy services will fall under Medicare Part B – however, there are specific Medicare guidelines for physical therapy in-home health services and doctor services.

It can be confusing to navigate the different coverage caps and figure out what Medicare therapy coverage you have. Let’s break it down.  

Physical Therapy for Back Pain

Medicare Physical Therapy Cap | Medicare Plan Finder
Medicare Physical Therapy Cap | Medicare Plan Finder

Back pain is one of the most common symptoms that leads to physical therapy. As you age, back pain is almost inevitable. It’s easy to fall into bad habits and poor posture. If you have back pain that lasts for a few weeks or longer, most doctors will recommend physical therapy.

A licensed and professional physical therapist will not only help you decrease pain but also educate you on how to prevent back pain in the future. He or she may even teach you some physical therapy exercises to perform at home.

Alternatively, seniors and Medicare eligibles who have a hard time getting to a doctor’s office may opt for a home nurse who is licensed to assist with physical therapy. In most cases, if your home nurse happens to double as a physical therapist, you will be covered under Part B.

Unfortunately, these services are not free.

How Much Does Medicare Pay for Physical Therapy?

Medicare Part B will cover your medically necessary outpatient therapy (physical, speech-language pathology, occupational) at 80%; you will be responsible for 20%. 

How Many Physical Therapy Sessions Will Medicare Cover?

In 2019, Medicare can start by covering up to 80% of $2,040 ($1,608) for physical and speech-language therapy services and another 80% of $2,040 ($1,608) for occupational therapy services.

According to Guidedoc.com, the average cost of physical therapy is about $100. Medicare would only cover about 20 of those $100 visits!

Once Medicare hits that limit, you and your doctor will need to reassess and provide proof that you need more coverage.

You will receive a written notice titled, “Advance Beneficiary Notice of Noncoverage.” The notice will tell you what Medicare will can or cannot continue to cover so that you can make informed choices about whether or not you want to continue your physical therapy.

Medicare Physical Therapy Billing

Medicare Physical Therapy Caps | Medicare Plan Finder
Medicare Physical Therapy Caps | Medicare Plan Finder

When it comes to paying the bills for your physical therapy, you may want to consider adding either a Medicare Advantage plan or a Medicare Supplement plan. Even though Original Medicare Part B covers physical therapy, the cap will hold you back. Adding Medicare Advantage or Medicare Supplements may give you the coverage you need to pay the bills.

The good news is that everyone who is eligible for Original Medicare is also eligible for Medicare Advantage and Medicare Supplement plans. You can’t have both, so you’ll have to choose one.

Medicare Advantage plans are offered by private insurance companies and are designed to add additional covered services like dental, vision, hearing, fitness, and in some cases even Medicare transportation benefits.

Alternatively, Medicare Supplement plans do not provide coverage for additional services but instead provide additional financial coverage. These plans are designed to help you pay for your coinsurance, copayments, and deductibles. You’ll have to decide what makes the most sense for you and your needs: more financial coverage, or more covered services?

Need A New Medicare Plan?

Our agents can help you decide if Medicare Advantage or Medicare Supplements are right for you. We have agents in 38 states and we’re constantly growing!

Plus, our agents are licensed to sell plans from all insurance carriers in your area, which means we are NOT biased. We can help you set up an appointment with an agent who will show you how to choose the right Medicare plan for your needs.

Most seniors and Medicare beneficiaries will have to wait until AEP (October) to change plans. Check out our post about Special Election Periods to see if you qualify for a SEP. Not sure if you qualify? That’s OK. Your licensed agent can help you find out if you qualify. Give us a call at 1-844-431-1832 or click here to have Medicare Plan Finder call you.

This post was originally published on January 4, 2018, and updated on August 24, 2018, and again on February 14, 2019, by Anastasia Iliou. Troy Frink updated the post on July 10, 2019.


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