What should I know about Medicare’s coverage of skilled therapy?
Skilled therapy are services that are reasonable and necessary to treat illness or injury, performed by or under supervision of a licensed therapist. 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): A type of 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.
Inpatient Skilled Therapy
Inpatient Rehabilitation Hospital
Rehabilitation hospitals are specialty hospitals or parts of acute care hospitals that offer intensive inpatient rehabilitation therapy. You may need inpatient care in a rehabilitation hospital if you are recovering from a serious illness, surgery, or injury and require a high level of specialized care that generally cannot be provided in another setting.
Medicare Part A may cover your inpatient rehabilitation hospital services (including skilled therapy) if this level of care is medically necessary. Speak with your doctor if you think this type of care is right for you
Skilled Nursing Facility (SNF)
SNFs are inpatient rehabilitation and medical treatment centers staffed with trained medical professionals who can perform skilled services. They may be attached to nursing homes or hospitals.
Medicare Part A may cover your SNF services (including skilled therapy) after a three day inpatient hospital stay 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
Speak with your doctor about your eligibility for Medicare covered SNF services.
Home health care includes a wide range of health and social services delivered in your home to treat illness or injury, including skilled therapy.
Medicare Part A or B may cover your home care depending upon your circumstances. In order to qualify for Medicare coverage of home care, you must be homebound, require intermittent skilled care, have a face to face meeting with a doctor and have them develop a plan of care with you, and receive services from a Medicare-certified home health agency.
Outpatient Skilled Therapy
Medicare Part B will cover outpatient therapy services in a doctor’s office, outpatient hospital setting, rehabilitation agency, Comprehensive Outpatient Rehabilitation Facility (CORF), or a public health agency.
You can also receive Part B-covered outpatient therapy services in a skilled nursing facility if you are there as an outpatient, private pay for your room and board, or are otherwise ineligible for a Medicare Part A-covered SNF stay. Part B may also cover outpatient therapy services received at home through home health agency therapists if you are ineligible for Part A coverage of home health care.
Original Medicare covers outpatient therapy at 80% of the Medicare-approved amount. When you receive services from a participating provider, you pay a 20% coinsurance after you meet your Part B deductible ($198 in 2020). 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.
Previously, there was a limit, also known as the therapy cap, on how much outpatient therapy Original Medicare covered annually. In 2018, the therapy cap was removed. However, if your total therapy costs reach a certain amount, Medicare requires your provider to confirm that your therapy is medically necessary. In 2020, Original Medicare covers up to $2,080 for PT, SPL and OT before requiring your provider to indicate that your care is medically necessary. Medicare pays for up to 80% of the Medicare-approved amount. This means Original Medicare covers up to $1,664 (80% of $2,080) before your provider is required to confirm that your outpatient therapy services are medically necessary. If your provider confirms that your therapy is medically necessary, your skilled therapy coverage should continue.