You may have heard or read about recent budget actions passed by Congress in April of 2015. These actions affect outpatient physical therapy benefits for people who have traditional Medicare Part B as their primary insurance. If you feel that you have a condition that might benefit from physical therapy, it is best to consult with your primary care provider. If your physician refers you to physical therapy, the benefits available to you are outlined below:
- You have $1,940 (based on allowed charges) available in physical therapy benefits for the CALENDAR year of 2015.
- Once the $1,940 level has been reached, the physician and physical therapist will have to determine the medical necessity of going over that amount. If they determine that continuing treatment is medically necessary, then you can continue in physical therapy as needed.
- Home health physical therapy and inpatient physical therapy do NOT contribute toward your allowed amounts for outpatient physical therapy.
- It does not matter whether you attend outpatient therapy at a private clinic or at a hospital outpatient clinic. Both settings follow the same dollar amount thresholds.
Patients with Medicare Advantage Plans (also known as Medicare Replacement Plans) do not usually follow the same threshold amounts as traditional Medicare plans. Each Medicare Advantage plan is different and may have requirements for pre-authorizations, copay amounts or certain networks. It is important to consult your own plan.
If you have any further questions about your Medicare coverage, visit www.medicare.gov, and you can type in the keyword “Physical Therapy” to get more information. You can also call our office for a free insurance verification to understand your benefits with your own insurance company. Knowing your insurance coverage is important as you plan how to use your benefits as well as how to spend your healthcare dollars. QCBN