Medicare no longer has a “therapy cap” for physical therapy services provided in a calendar benefit periodThe benefit period is the amount of time you are covered by Medicare Part A, beginning the day you're admitted as an inpatient and ending once you haven't gotten any inpatient care for 60 days in a row..
Medicare covers several types of therapy, including mental health, physical therapy, occupational therapy, speech therapy and behavioral therapy.
Medicare will cover 80% of Medicare-approved costs for your therapy; Part B deductible applies. You are responsible for 20% of the costs.
In most cases, your doctor or provider must affirm that therapy is medically necessaryHealthcare services that are necessary for the diagnosis or treatment of an illness, injury, condition, disease or symptoms..
Medicare Part A covers medically necessary inpatient rehab (rehabilitation) care, which can help when you’re recovering from serious injuries, surgery or an illness. For inpatient rehab care to be covered, your doctor needs to affirm the following are valid for your medical condition:
- It requires intensive rehab.
- It needs continued medical supervision.
- It needs coordinated care from your doctors and therapists working together.
Part A also covers inpatient mental health services and therapies. Part A covers treatment for symptoms like depression or anxiety in a general hospital and specialized treatment for a mental health disorder in a psychiatric hospital. Keep in mind that your benefit period for treatment at a general hospital will reset between multiple hospital stays. However, inpatient mental health treatment at a psychiatric hospital is limited to 190 days over a lifetime.
Medicare Part B covers outpatient therapy, including physical therapy, speech-language therapy and occupational therapy. Also, Part B covers mental and behavioral services and counseling deemed medically necessary or assists in an improved health outcome related to another diagnosis. For example, suppose weight loss was a crucial part of your disease management plan. In that case, Medicare may cover behavioral weight loss counseling if a qualified provider gives the counseling in a primary care setting.
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Suppose you are enrolled in Medicare and need therapy. In that case, you’ll be pleased to know that Medicare has made giant strides for beneficiaries that depend on therapy for improving or maintaining their physical health. Previously, Medicare beneficiaries were limited to a therapy cap, which regulated the amount of treatment Medicare would cover in a benefit period. However, beneficiaries no longer have a therapy cap in their coverage.
You have two essential things to keep in mind regarding costs.
Medicare does not pay for all of your therapy.
- Like other medical services covered, Medicare pays a portion of Medicare-approved costs, and the Part B deductible applies. After you meet the Part B deductible, Medicare pays 80% of the bill, and you are responsible for the other 20%.
Your therapy needs to be medically necessary.
- You don’t have a therapy cap, but when your therapy costs reach a certain amount ($2,150 in 2022), Medicare requires your provider to affirm that your treatment is medically necessary. In some cases, Medicare can deny coverage.
Does Medicare cover speech-language therapy?
If you require an evaluation or treatment to regain and strengthen or maintain current function or slow decline of speech and language skills, you may be covered by Medicare. Part B coverage can include cognitive and swallowing abilities. Medicare Part B helps pay for medically necessary outpatient speech therapy services if your doctor certifies you need it.
Does Medicare cover occupational therapy?
If you need therapy to help you perform daily living activities, like dressing or bathing, Medicare Part B will cover a portion of the services delivered. Occupational therapy helps beneficiaries maintain daily capabilities or slow decline. Part B helps pay for medically necessary outpatient occupational therapy.
Does Medicare cover physical therapy?
Medicare no longer limits how much it pays for your medically necessary outpatient therapy services in one calendar year. Your Part B coverage will pay 20% of your costs after you meet the Part B deductible and your therapy is delivered:
- At a doctor’s or therapist’s office.
- Inside hospital outpatient departments.
- At outpatient rehabilitation facilities.
- At skilled nursing facilities, if you are outpatient.
Medicare does provide coverage for therapy, as well as for counseling and other mental health care needs. Medicare Part A provides coverage for inpatient services. Medicare Part B provides coverage for things like treatment and services at a doctor’s office. Typically, the cost sharing of your Medicare plan means that after you meet the deductible, your coverage pays 80% of Medicare-approved costs, and you are responsible for 20% of costs.
In some instances, you may have a copay. Yet, a service like behavioral counseling for weight loss is covered at 100% if you qualify for the service.
If you’re not sure how to figure out the costs for a service, you can always contact your plan or provider’s office to learn what to expect regarding cost.
Are you eligible for cost-saving Medicare subsidies?
Medicare Part A and Part B cover a wide range of mental health services. Part A provides your coverage if you need emergency or psychiatric care delivered at a hospital or psychiatric facility. For outpatient counseling and therapy, or mental health screening, Part B provides your coverage.
Medicare Part B pays for one depression screening each year. Your Part B coverage requires that this appointment take place in your doctor’s office. If you need individual therapy, group therapy or family therapy, Medicare Part B may cover your care when it’s considered part of your doctor’s treatment plan. For these services to be covered, your care must be provided by:
- A psychiatrist.
- Clinical psychologists.
- Clinical social workers.
- Clinical nurse specialists.
- A nurse practitioner.
Your Part A and Part B deductibles will apply with mental health coverage. You may have to pay coinsurance and copays for mental health services. If you are prescribed medications as part of your treatment, Medicare Part D will cover prescription drugs.
How much does Medicare cover behavioral and nutrition counseling?
Medicare Part B covers intensive behavioral therapy for obesity if you need help losing weight if you are obese. You must complete a body mass index (BMI) screening (covered by Part B) to qualify. If you score a BMI of 30 or higher, you are considered obese.
Medicare will cover a programmed number of sessions, including:
- One in-person visit with your doctor every week for the first month.
- One in-person visit with your doctor every other week from months two to six.
- One in-person visit with your doctor each month during months seven to 12.
You will be re-screened after your first six months of counseling. If you show progress at the end of the first six months, you can be eligible for months seven to 12. If you don’t show improvement after the first six months (a loss of 6.6 lbs is the minimum), Medicare may stop your therapy.
Original Medicare covers behavioral counseling at 100% (no deductible or coinsurance) of the Medicare-approved amount. Medicare Advantage plans cover the same when you see an in-network provider.
If you have Original Medicare Part A and Part B, your coverage no longer limits how much it will pay for medically necessary therapy services. However, if you have a Medicare Advantage plan, you should check your plan to learn about its coverage for therapy services, as your HMO or PPO benefits may differ.
Does the number of medically necessary therapy sessions impact your costs? No. After you pay your Part B deductible, you’ll pay 20% of the cost. Medicare will pay 80%.
Will Medicare cover any of your therapy sessions if they aren’t medically necessary? Medicare only pays for therapy services that are considered essential. Also, you must receive your therapy sessions from an approved provider, which can include:
What extra benefits and savings do you qualify for?