Health Insurance for Therapy Services

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Many changes are taking place in healthcare. This month we discuss what some of these changes mean for Medicare Beneficiaries. Not to worry, next month we will feature information on broader healthcare plans and explain what the deductible, co-insurance, etc. mean for you. Our goal is to help you understand and optimize what health insurance does for you. We want to provide information so all of our patients and clients can be educated consumers of healthcare.

Currently, there is legislation under review that can drastically change Medicare services. If you or your family members rely on Medicare for healthcare coverage, now is the time to learn more and contact your representatives. The American Physical Therapy Association has resources dedicated to helping you understand coverage and what you can do to ensure you get the most out of your Medicare coverage. Visit for more information.

Healthcare benefits and coverage are very dynamic. Medicare currently has a “patch” on the Medicare therapy cap and other restrictions. The Medicare therapy cap limits outpatient occupational therapy services to $1960 per calendar year. For physical and speech therapy outpatient services there is a combined $1960 cap. Medicare counts the allowable billed dollar amount from each therapy session toward this cap. In certain situations, i.e. PT after knee surgery in February and then PT for hip pain with walking could create a situation where the cap is reached. It is important to communicate with your legislators to minimize these types of limitations to your care. Medicare requires that all therapy services have medical necessity of a complexity sufficient that only the skills of a licensed physical/occupational/speech therapist are adequate for intervention. Additionally, these regulations still apply to your supplementary insurance coverage in most circumstances. If your yearly therapy expenses reach $3,700 your case is subject to a manual medical review.

As Medicare is federally funded healthcare, the language for beneficiaries can be challenging to understand. This link is your home page for information. Medicare is a national program, however, each state has agencies (LCDs) contracted to provide assistance and coverage at the local level. The state of Wisconsin contracts NGS to determine local coverage. Key points of the most recent determination can be found at A few highlights are below.

-Medical necessity is required

For physical therapy this means your care must require the unique skills and professional services of a physical therapist of physical therapist assistant. Services such as general health, fitness, flexibility or recreational services are deemed non-rehabilitative or repetitive. If you are fortunate to have a supplementary insurance policy, it may cover sports injuries or contain a wellness benefit. For Medicare Part B these services are not covered. For these needs Vita offers self-pay personal training and the trainers are always able to consult with the physical therapists for specific needs.

-A physician must sign your therapy plan of care

If you start physical therapy with direct access (no prescription), then your physical therapist must have your physician sign your physical therapy plan.

Your physical therapy must contain skilled services of a level of complexity or patient condition such that they can only be safely and effectively performed by a physical therapist or physical therapist assistance. The quick way to know who on the therapy team is providing care is to ask about their license. Both PT’s and PTA’s are licensed by the state of Wisconsin and approved by Medicare to provide physical therapy.

-Transient issues are not covered

Some orthopedic injuries get better with time and gradual resumption of activities. Medicare will not cover therapy if you are reasonably expected to return to function as discomfort reduces. This can be difficult to determine, so Vita offers free injury screening to help determine medical necessity.

In short, Medicare requires physical therapy services to be individualized, medically necessary, and require the unique skills of a physical therapist. There is no benefit for fitness packages or group programs. A maintenance program can be designed by a PT, however, the patient must independently carry out the program. No more than 2-4 visits over a 3-4 month period of time will be covered for a maintenance program.

-Tommy Grabowski, Doctor of Physical Therapy
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