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does medicare cover physical therapy in florida

Does Medicare cover physical therapy?

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Dear Connie,

My husband fell recently. He suffered a head injury and a broken ankle. He hasn’t been himself since. I try to get him out of bed and active, but he’s not interested.

Some friends told me that physical therapy might help with his recovery, but it’s not something that our doctor mentioned. I’m not sure if it’s useful, and I’m wondering, does Medicare cover physical therapy?

Preventing another fall,
Brenda and Ronald from Winter Park, Florida

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Dear Brenda and Ronald,

I’m so sorry to hear that Ronald’s fall left him with injuries. The Centers for Disease Control and Prevention (CDC) reports that one in every five falls results in a head injury or broken bone. In Ronald’s case, I’m sorry to hear that both occurred.

Unfortunately, this fall does double his chances of falling again. That’s why it’s vital that we get Ronald up and moving. While a fall can sometimes shatter someone’s confidence and leave them with injuries, movement may be precisely what’s needed. Movement can help increase his strength and prevent additional falls.

Agent tip:

“A Medicare Advantage plan offers the same level of care as Original Medicare but with added benefits such as dental, vision, and hearing. Some Medicare Advantage plans also include expanded physical therapy coverage.“

In addition to movement, making the home safer is also vital. Since he’s fallen once, we want to remove anything that may cause additional falls and injuries.

Aging-in-place home modifications include:

  • Adding grab bars inside and outside your tub or shower and next to the toilet.
  • Ensuring handrails are installed on both sides of the stairs.
  • Increasing the lighting in the house by adding more lights or increasing the brightness of your light bulbs.
  • Removing all small area rugs and more.

There are state and local government education and/or home modification programs that can help you improve your home to prevent additional falls. If you need support with home modifications, you could search the Eldercare Locator or call 1-800-677-1116 to find the local Area Agency on Aging to see if there is an Aging in Place program or home modifications financial support.

We like that your friends suggested that Ronald seek physical therapy support. While exercise may be the last thing he wants to do, in many ways, movement is needed. A physical therapist can help decrease stiffness, which may lead to increased mobility.

If his doctor hasn’t recommended physical therapy, the first step is to reach out to them and ask whether it’s possible to get. While Original Medicare Part B does help pay for outpatient physical therapy, it must be under the care of a doctor or health care provider (nurse practitioner, clinical nurse specialist, or physician assistant).

Once you have the doctor or health care provider’s sign-off, Ronald could get up to $2,230 worth of physical therapy care in 2023 without a therapist proving it’s medically necessary. That is the cap Medicare puts on physical therapy (PT) and occupational therapy (OT) services. That amount will count towards the annual threshold if he receives PT or OT services.

These physical therapy sessions can occur at a doctor’s or therapist’s office, at a hospital outpatient department, an outpatient rehab facility, at an outpatient, skilled nursing facility, or at home through a Medicare-certified home health agency. Whether he needs outpatient or inpatient care will determine the costs. In this scenario, I’m assuming that he needs outpatient care.

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There are some costs involved if you only have Original Medicare. You would need to pay the Original Medicare Part B deductible ($240 in 2023), then you would pay 20% of out-of-pocket costs. Part B would pay the other 80% of the Medicare-approved amount.

For instance, the national average for a physical therapy treatment session is $50 – $155, depending on your location and the provider’s expertise. If a physical therapy services session costs $103, your out-of-pocket cost would be $20.60 after the Part B deductible. Medicare Part B would pay $81.90 for the session.

Original Medicare does not have an out-of-pocket maximum, which is why many people enroll in a Medigap plan (Medicare Supplement Insurance) or Medicare Advantage plan. A Medicare Supplement plan can help pay for some or all of the out-of-pocket costs.

A Medicare Advantage plan offers the same level of care as Original Medicare but with added benefits such as dental, vision, and hearing. Some Medicare Advantage plans also include expanded physical therapy coverage.

I hope this information answers your questions about whether Medicare covers physical therapy and helps your husband access care. An at-home physical therapist may help him get out of bed and moving.

At Connie Health, we help you throughout your Medicare journey. We would be happy to review plan options that offer extended physical therapy benefits or help protect you and your husband from high out-of-pocket costs. If you have additional coverage questions, contact a local licensed Connie Health agent at (623) 223-8884 (TTY: 711).

Sources

2023 Medicare Physician Fee Schedule Final Rule.

Facts About Falls.

Physical Therapy Pricing Guide.

Preventing Falls at Home: Room by Room.

Updated: February 23, 2023

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Frequently Asked Questions

Does Medicare pay for physical therapy?
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Yes, Original Medicare Part B helps pay for outpatient physical therapy.

You would need to pay the Medicare Part B deductible, then 20% of out-of-pocket costs. Original Medicare Part B would pay for the remaining 80% of the Medicare-approved amount.

You could get up to $2,230 worth of physical therapy care in 2023 without a therapist proving it’s medically necessary. That is the cap Medicare puts on physical therapy (PT) and occupational therapy (OT) services. That amount will count towards the annual threshold if you receive PT or OT services.

How many physical therapy sessions does Medicare cover?
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There isn’t a set number of physical therapy sessions that Medicare covers. Instead, coverage is based on the annual dollar amount of coverage.

You could get up to $2,230 worth of physical therapy care in 2023 without a therapist proving it’s medically necessary. That is the cap Medicare puts on physical therapy (PT) and occupational therapy (OT) services. That amount will count towards the annual threshold if you receive PT or OT services.

After $2,230, you must have documentation that your physical therapy is medically necessary.

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Read more by William Revuelta

I am a Spanish-speaking Florida Life and Health Insurance Licensed Agent and have been helping people with Medicare since 2009. I’m an avid sports fan and enjoy watching international soccer matches and college football. When not with my family, I listen to podcasts ranging from history to sports talk.

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