Dear Marci,
I have been struggling with back pain. My doctor prescribed me physical therapy, but I am not sure what coverage or costs I should expect. How does Medicare cover outpatient skilled therapy?
- Cameron (Bangor, ME)
Dear Cameron,
Skilled therapy services are services from licensed therapists or skilled therapy providers. There are three main types of skilled therapy covered by Medicare:
- Physical therapy (PT): Exercise and physical activities used to condition muscles and improve levels of activity. It is helpful for those with physically debilitating illness. PT will help you regain movement and strength in a body area.
- Speech/language pathology (SLP): Therapeutic treatment of speech impairments (such as lisping and stuttering) or speech difficulties that result from illness. SLP will help you regain and strengthen speech and language skills.
- Occupational therapy (OT): Therapy using meaningful activities of daily living to assist people who have difficulty acquiring or performing meaningful work due to impairment or limitation of physical or mental function. OT helps you regain the ability to do usual daily activities by yourself such as eating and putting on clothes.
People commonly get skilled therapy on an outpatient basis. Medicare Part B will cover skilled therapy when received as an outpatient (not formally admitted to a hospital or skilled nursing facility). You can get therapy services in a doctor’s office, outpatient hospital setting, rehabilitation agency, Comprehensive Outpatient Rehabilitation Facility (CORF), public health agency, or your home (if your home health care is covered by Part B). You are eligible for Medicare coverage of outpatient therapy services if:
- You need skilled therapy services, and the services are considered safe and effective treatment for you
- Your doctor or therapist creates a plan of care before you start receiving services
- Your doctor or therapist regularly reviews the plan of care and makes changes as needed
If you meet Medicare’s eligibility requirements, Medicare covers therapy on a temporary basis to improve or restore your ability to function, or on an ongoing basis to prevent you from getting worse. Medicare should cover your outpatient therapy regardless of whether your condition is temporary or chronic.
Original Medicare covers outpatient therapy at 80% of the Medicare-approved amount and you may pay a 20% coinsurance after you meet your Part B deductible ($198 in 2020). There is no cap for how much outpatient therapy Medicare covers each year. However, once you reach $2,080 in total therapy costs in 2020, Medicare requires your provider to confirm that your therapy is medically necessary. If you are in a Medicare Advantage Plan, your costs may differ. You should contact your plan directly to find out what your estimated costs may be.
- Marci
