SAVVY SENIOR: Medicare and physical therapy

Dear Savvy Senior,

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

Need Help

Dear Need,

Medicare covers a variety of outpatient therapy services including physical, occupational and speech therapy, if you meet their coverage criteria.

To get Medicare (Part B) to help cover your physical therapy, it must be considered medically reasonable and necessary, and will need to be ordered or prescribed by your doctor.

You can get these services as an outpatient at a number of places like a doctor’s or therapist’s office, rehabilitation facility, medical clinic or a hospital outpatient department.

You also need to know that Medicare limits how much it pays 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.

But be aware that just like with other Medicare covered services, Medicare will pay 80 percent (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 percent until the cap limits are reached. After that, you’ll have to pay the full cost for the services.

If, however, you reach your cap limits and your doctor or therapist recommends that you continue with the treatment, you can ask your therapist for an exception so that Medicare will continue to pay for your therapy. The therapist must provide documentation 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.

If you choose to get physical therapy on your own 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, but the ABN lets you decide whether to get them.

Therapy at home

You should also know that Medicare covers home therapy services too if you are 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.

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. But 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.

If you have other questions, call Medicare at 800-633-4227, or contact your State Health Insurance Assistance Program (SHIP), who 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.

Send your senior questions to: Savvy Senior, P.O. Box 5443, Norman, OK 73070, or visit SavvySenior.org. Jim Miller is a contributor to the NBC Today show and author of “The Savvy Senior” book.