Medicare covers three main types of outpatient rehabilitation therapy:
- Physical therapy
- Occupational therapy
- Speech-language pathology services
Medicare Part B pays 80 percent of the Medicare-approved amount for outpatient therapy services received from a provider who accepts Medicare assignment. You are responsible for 20 percent of the cost after meeting the Part B deductible.
Your costs for Medicare rehab coverage with a Medicare Advantage plan (Part C) depend on the specific plan you have. Medicare Advantage plans are offered by private insurance companies and approved by Medicare. These plans must provide coverage at least as good as what’s provided by Original Medicare (Parts A & B).
Is there a limit on Medicare coverage for outpatient therapy?
Technically, no. There is no limit on what Medicare will pay for outpatient therapy, but after your total costs reach a certain amount, your provider must confirm that your therapy is medically necessary in order for Medicare to cover it.1
In 2020, your provider must confirm your therapy is medically necessary once your total costs reach $2,080 for physical therapy, speech-language pathology or occupational therapy care. Original Medicare (Parts A & B) will continue to pay for up to 80 percent of the Medicare-approved amount once your care is confirmed as medically necessary. Your costs with a Medicare Advantage plan may be different, so ask your provider before seeking care.
What if your physical therapy isn’t medically necessary?
Your provider must notify you before providing care that is not medically necessary so you can decide whether you want the services. This is true for physical therapy, speech-language pathology and occupational therapy. This notice is called an Advance Beneficiary Notice of Noncoverage (ABN). If your provider gives you an ABN, you may agree to pay for the services that aren’t medically necessary. However, Medicare will not help cover the cost.
What is the Medicare therapy cap?
The Medicare therapy cap was a set limit on how much Original Medicare would pay for outpatient therapy in a year. Once that limit was reached, you had to request additional coverage through an exception in order to continue getting covered services. However, by law, the therapy cap was removed entirely by 2019.
Where can you get outpatient therapy services?
Medicare covers outpatient therapy services that you get from physical therapists, occupational therapists, speech-language pathologists, doctors and other health care professionals. The services may be provided in the following locations:
- A therapist’s or doctor’s office
- A rehabilitation agency
- A comprehensive outpatient rehabilitation facility (CORF)
- A skilled nursing facility when you’re there as an outpatient
- Your home, from certain therapy providers, when you’re not eligible for Medicare’s home health benefit
A special note about coverage in a skilled nursing facility or at home: The coverage rules for outpatient therapy above don’t apply if your therapy is part of a Medicare-covered stay in a skilled nursing facility or if you’re receiving home health care. You’ll need to contact your Medicare provider to understand how the costs and coverage rules apply for these situations, as they could vary.
Remember, if you need outpatient therapy care, make sure to always get confirmed proof from the care provider that the therapy is medically necessary. Nobody wants to get caught off-guard by extra costs later.
Further reading: Medicare coverage for inpatient rehabilitation therapy.
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