Will medicare pay for physical therapy without a referral

Medicare can help pay for physical therapy (PT) that’s considered medically necessary. After meeting your Part B deductible, Medicare will pay 80 percent of your PT costs.

PT can be an important part of treatment or recovery for a variety of conditions. It focuses on restoring functionality, relieving pain, and promoting increased mobility.

Physical therapists work closely with you to treat or manage a variety of conditions, including but not limited to musculoskeletal injuries, stroke, and Parkinson’s disease.

Keep reading to find out which parts of Medicare cover PT and when.

Medicare Part B will help to pay for outpatient PT that’s medically necessary. A service is considered medically necessary when it’s needed to reasonably diagnose or treat a condition or illness. PT can be considered necessary to:

• improve your current condition
• maintain your current condition
• slow further deterioration of your condition

For PT to be covered, it must involve skilled services from a qualified professional like a physical therapist or doctor. For example, something like providing general exercises for overall fitness wouldn’t be covered as PT under Medicare.

Your physical therapist should give you a written notice before providing you with any services that wouldn’t be covered under Medicare. You can then choose whether you want these services.

Let’s further break down the different parts of Medicare and how the coverage provided relates to PT.

Part A

Medicare Part A is hospital insurance. It covers things like:

• inpatient stays at facilities like:
  • hospitals
  • mental health facilities
  • rehabilitation centers
  • limited stays at skilled nursing facilities
• hospice care
• limited home healthcare

Part A can cover inpatient rehabilitation and PT services when they’re considered medically necessary to improve your condition after hospitalization.

Part B

Medicare Part B is medical insurance. It covers medically necessary outpatient services. Part B may also cover some preventive services.

Medicare Part B covers medically necessary PT. This includes both the diagnosis and treatment of conditions or illnesses that affect your ability to function.

You can receive this type of care at the following types of facilities:

• medical offices
• privately practicing physical therapists
• hospital outpatient departments
• outpatient rehabilitation centers
• skilled nursing facilities (when Medicare Part A doesn’t apply)
• at home (using a Medicare-approved provider)

Part C

Medicare Part C plans are also known as Medicare Advantage. Unlike parts A and B, they’re offered by private companies that have been approved by Medicare.

Part C plans include the coverage provided by parts A and B. This includes medically necessary PT. If you have a Part C plan, you should check for information regarding any plan-specific rules for therapy services.

Part C plans can also cover some services not included in parts A and B, such as dental, vision, and prescription drug coverage. What’s included in a Part C plan varies by plan, company, and location.

Part D

Medicare Part D is prescription drug coverage. Similar to Part C, private companies approved by Medicare provide Part D plans. The medications that are covered can vary by plan.

Part D plans don’t cover PT. However, if prescription medications are a part of your treatment or recovery plan, Part D may cover them.

Medigap

Medigap is also called Medicare supplement insurance. These policies are sold by private companies and can cover some costs that aren’t covered by parts A and B. This can include:

• deductibles
• copayments
• coinsurance
• medical care when you’re traveling outside the United States

Although Medigap may not cover PT, some policies may help to cover the associated copayments or deductibles.

The cost of PT can vary greatly and many factors can affect the cost, including:

• your insurance plan
• the specific type of PT services that you need
• the duration or number of sessions involved in your PT treatment
• how much your physical therapist charges
• your location
• the type of facility you’re using

Copay can also be a bigfactor in PT costs. In some cases, the copay for a single session can be as high as $75. If you need to have many sessions of PT, this cost can quickly add up.

A study from 2019 found that the average PT expenditure per participant was $1,488 per year. This varied by diagnosis, with neurological conditions and joint replacement expenditures being higher while genitourinary conditions and vertigo were lower.

Coverage and payments

Once you’ve met your Part B deductible, which is $203 for 2021, Medicare will pay 80 percent of your PT costs. You’ll be responsible for paying the remaining 20 percent. There’s no longer a cap on the PT costs that Medicare will cover.

After your total PT costs exceed a specific threshold, your physical therapist is required to confirm that the services provided remain medically necessary for your condition. For 2021, this threshold is $2,110.

Your physical therapist will use documentation to show that your treatment is medically necessary. This includes evaluations of your condition and progress as well as a treatment plan with the following information:

• diagnosis
• the specific type of PT you’ll be receiving
• the long-term goals of your PT treatment
• amount of PT sessions you’ll receive in a single day or single week
• total number of PT sessions needed

When total PT costs exceed $3,000, a targeted medical review may be performed. However, not all claims are subject to this review process.

Medicare parts A and B (original Medicare) cover medically necessary PT. If you know you’ll need it in the coming year, having just these parts may meet your needs.

If you’re concerned about additional costs that aren’t covered by parts A and B, you may want to think about adding a Medigap plan. This can help to pay for things like copays, which can add up during PT.

Part C plans include what’s covered in parts A and B. However, they may also cover services that aren’t covered by these parts. If you’ll need coverage of dental, vision, or fitness programs in addition to PT, consider a Part C plan.

Part D includes prescription drug coverage. It can be added to parts A and B and is often included in Part C plans. If you already take prescription medications or know that they may be a part of your treatment plan, look into a Part D plan.

Medicare Part B covers outpatient PT when it’s medically necessary. Medically necessary means that the PT you’re receiving is required to reasonably diagnose or treat your condition.

There’s not a cap on the PT costs that Medicare will cover. However, after a certain threshold your physical therapist will need to confirm that the services you’re receiving are medically necessary.

Other Medicare plans, such as Part C and Medigap, can also cover costs associated with PT. If you’re looking at one of these, remember to compare several plans before selecting one since coverage can vary by plan.