Sep 15, 2017

Medicare and You.png 

Physical Therapy and Medicare

 by Janet Hustak, PTA/Office Manager 


So many patients and their families have questions about their insurance coverage.  Commercial policies all have their own practices they follow.   Medicare provides coverage to all Americans aged 65 and older who have worked and paid into the system, as well as younger people with disabilities.


So how is Medicare different from the “Commercial policies”?  Medicare is designed to absorb risk, whereas commercial insurers are always looking at ways to minimize their exposure to risk.  Medicare provides coverage to healthy as well as those who currently have expensive or complex medical issues.  Commercial insurers on the other hand, must protect their business interests by avoiding those most likely to use medical care.


All Medicare benefits are determined by medical necessity, which means that physical therapists must provide care that is justifiably reasonable and necessary.  Do you need a prescription from  the doctor to come to physical therapy?  No, Nebraska law states that individuals have the right to direct access; however Medicare does require physical therapists to coordinate the plan of care with your physician.


The most asked question about Medicare is “How much is this going to cost me?”  Medicare helps pay for medically necessary outpatient physical, occupational, and speech pathology services when the licensed therapist establishes a plan of care and the licensed physician periodically reviews the plan to see how the patient is progressing.  Regarding copayment, the patient pays 20% of the Medicare approved amounts; after an annual deductible of $183 in 2017.  It has been my experience that this 20% copayment is covered by the supplement policies, most of the time. 


The second most asked question is “Does Medicare have a limit on how many times I can come to physical therapy?”  Medicare law limits how much it pays during a one calendar year.  These limits are called “therapy caps”.  The 2017 therapy cap is $1,980 for physical therapy and speech pathology services combined; as well as a second therapy cap of $1,980 for occupational services.  Are there any exceptions to the therapy cap?  You may qualify for an exception (which would allow Medicare to pay for services after you reach the therapy cap limit).  Your therapist will establish your need for medically reasonable services and document this in your medical records.  Your therapist will also indicate on your Medicare claim for services above the therapy cap limit.


Is there a way to continue Physical Therapy if Medicare no longer pays?  Yes.  By signing an Advance Beneficiary Notice of Noncoverage (ABN) you are agreeing to pay for physical therapy out of your pocket.  A cash price can be determined between you and your physical therapist.



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