Medicare Coverage Of Therapy And Mental Health Benefits
Contributing expert: Kelly Blackwell, Certified Senior Advisor®Medicare beneficiaries can access mental health care benefits through Original Medicare Part A for inpatient care and Part B for outpatient services or through a Medicare Advantage plan. Mental health coverage through Medicare supports optimal emotional, psychological, and social well-being.Updated: December 07, 2021
Kelly Blackwell is a Certified Senior Advisor ®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
How Do Different Health Insurance Plans Cover Physical Therapy
Whether or not your health insurance plan covers physical therapy costs depends on several factors.
A major factor is the type of health plan you have. For example:
- Employer-sponsored or job-based policies are more likely than most kinds of health insurance policies to pay for physical therapy.
- Individual health insurance policies, especially ones that are bought from the federal or state marketplace, often cover physical therapy, too. But they dont always cover it well.
- If youre on Medicare, youre in luck. Medicare Part B covers many forms of physical therapy to an extent.
- People on Medicaid arent as lucky. Federal law treats physical therapy as an optional benefit in terms of this program. That means states can choose to cover it or not. Some do, but many dont.
Keep reading to learn more about how these different health insurance plans do and dont cover physical therapy.
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How Long Does Medicare Pay For Rehab
Medicare Part A covers 100 days in a skilled nursing facility with some coinsurance costs. After day 100 of an inpatient SNF stay, you are responsible for all costs.
Medicare Part A will also cover 90 days of inpatient hospital rehab with some coinsurance costs after you meet your Part A deductible. Beginning on day 91, you will begin to tap into your lifetime reserve days.”
You may have to undergo some rehab in a hospital after a surgery, injury, stroke or other medical event. The rehab may take place in a designated section of a hospital or in a stand-alone rehabilitation facility.
Medicare Part A provides coverage for inpatient care at a hospital, which may include both the initial treatment and any ensuing rehab you receive while still admitted as an inpatient.
When you have been out of the hospital for 60 days in a row, your benefit period ends and your Part A deductible will reset the next time you are admitted.
Your rehab could potentially take place in a skilled nursing facility . When you enter a skilled nursing facility, your stay will typically be covered in full for the first 20 days of each benefit period .
Days 21 to 100 of your stay will require a coinsurance payment of $194.50 per day in 2022, and you will then be responsible for all costs beginning on day 101.
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How Much Does Therapy Cost With A Medicare Plan
Therapy with Medicare will cost different amounts depending on your location, plan, and provider:
- Location: Even though Medicare is a federal health insurance program, each state is responsible for its own Medicare policies. This means that Medicare plans look different across state lines.
- Plan: Receiving your Medicare coverage directly from the state or through a health insurance company will impact your coverage. Sometimes, health insurance companies offer different benefits and have access to different resources.
- Provider: Not all therapists take Medicare for the therapists that do not, you will have to pay the session costs.
In general, for an in-network Medicare provider, expect to pay a copayment or coinsurance for each visit to your therapist. Medicare copayments are generally around $20 and coinsurance rates around 20%, though these will vary based on your situation. For out-of-network therapists, you will typically be responsible for a larger portion of the session fee. Seeing a non-Medicare therapist also may require preauthorization from your Medicare plan.
It is important to note that some Medicare plans limit the number of therapy sessions for which a person receives coverage. Some plans are limited by visit number or by cost . Before starting therapy, learn if your plan limits your care so you dont have to stop in the middle of your treatment.
Original Medicare And Physical Therapy Costs
Both Medicare Part A and Part B will help cover physical therapy expenses. But context matters. Medicare Part A will only pay for physical therapy if you are admitted to the hospital as an inpatient for at least 3 days.
Here are the expenses you can expect if you get physical therapy in a hospital:
- A Part A deductible
- Daily coinsurance costs
- 100% of the cost of medically unnecessary physical therapy
- Part B excess charges
Its a little different for Medicare Part B. Heres what you have to do to make sure Medicare pays for your physical therapy under Part B:
- Establish medical necessity with your doctor
- Pay your annual deductible, which is
- Pay 20% coinsurance for the Medicare-approved amount of your physical therapy
Keep in mind that these estimates are for Original Medicare only. You can help reduce your own expenses by purchasing a Medicare supplement. Whether that supplement is Medigap or a Medicare Advantage plan is up to you.
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How Do You Get In
If you suffer an injury or illness that limits your ability to move around normally, you may benefit from PT. And if you cannot leave the house, home-care physical therapy may be the best option.
Most patients who receive home-care physical therapy are referred to the service by their healthcare provider. Your healthcare provider can make the referral to a local visiting nurse service that offers physical therapy, and he or she can attest that home services are medically necessary. This medical necessity report will likely also state that home-care physical therapy is needed because you are unable to leave the house due to your condition or circumstances.
If you feel you may benefit from physical therapy at home, you can also call your local physical therapy clinic or visiting nurse association. Those organizations can help you navigate the pathway to receiving home-care PT.
Medicare does indeed cover services to maintain or manage a beneficiarys current condition when no functional improvement is possible.
Several nonfederal payers also have clarified their policies regarding the improvement standard and skilled maintenance coverage.
Does Medicare Cover Prescription Drugs For Mental Health
Stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans can vary in both costs and which drugs are covered. To find out if a medication you need is covered by a specific Medicare plan that offers prescription drug coverage, check the plans drug formulary, which is a list of medications covered by the plan. The formulary may change at any time. You will receive notice from your plan when necessary.
Medicare Part D covers prescription drug benefits you may need for treatment of your condition. Original Medicare, Part A and Part B, doesnt include drug coverage, although Medicare Part B covers some medications that cant be self-administered, such as drugs given by injection. For other prescription coverage, however, beneficiaries with Original Medicare must enroll in a separate Medicare Part D prescription drug plan. Medicare Advantage enrollees can get drug coverage through a Medicare Advantage Prescription Drug plan, which includes Medicare Part A, Part B, and Part D benefits under a single plan.
Certain drugs that treat mental health conditions are in protected classes under Medicare Part D, including antipsychotic drugs, antidepressant drugs, and anticonvulsant drugs. With some exceptions, Medicare Part D prescription drug plans must cover most medications in these drug classes.
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Does Medicare Cover In
Medicare Part B medical insurance will cover at home physical therapy from certain providers including private practice therapists and certain home health care providers.
If you qualify, your costs are $0 for home health physical therapy services. But you will pay 20 percent of the Medicare-approved amount for durable medical equipment wheelchairs, walkers and other such medical devices and equipment.
You have to have Medicare Part A and/or Part B and meet all items on a list of requirements from Medicare to be eligible for at home therapy.
Medicare Eligibility for Home Physical Therapy Coverage
- You must be under the care of a doctor.
- You must have a plan of care your doctor created and regularly reviews.
- A doctor must certify that you need one or more of these:
- Intermittent skilled nursing care other than drawing blood.
- Physical therapy scheduled over a reasonable time frame that is specific, safe and effective treatment for your condition by a Medicare-approved provider.
- That you are homebound.
You are not eligible for home PT services if you need more than part-time skilled nursing care. You may still get home services if you attend adult day care. You may still be considered homebound even if you leave home for medical treatment or short, rare nonmedical reasons such as attending religious services.
Does Medicare Pay For In
Medicare Part B coverage includes outpatient physical therapy services delivered in a clinic or in the patient’s home. This is a great benefit to Medicare beneficiaries who have completed home health physical therapy under Medicare Part A and are now planning to transition to outpatient therapy services.
Mobile physical therapists who are contracted with Medicare part B may bring all of the skill and convenience to your home.
Some of the more common conditions treated by a physical therapist in the patient’s home include post surgical care for individuals who have received a total knee replacement, total hip replacement, and rotator cuff repair.
If you have been referred to outpatient physical therapy services and would like to find a physical therapist in your area that is a contracted Medicare provider and able to deliver covered services.
If you would like to find therapists in your area please use our search feature.
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Do Medicare Supplement Insurance Plans Cover Physical Therapy
Medicare Supplement insurance plans are designed to help pay your out-of-pocket costs under Part A and Part B. Plans sold today do not pay any costs associated with Medicare Part D prescription drug plans, and they cant be combined with a Medicare Advantage plan.
Medicare Supplement insurance plans are sold by private insurance companies. Medicare Supplement basic benefits are standardized and set by the federal government. In most states, there are standardized plans with lettered names, such as Medicare Supplement Plan G. What this means is that Medicare Supplement Plan G sold by one insurance company has essentially the same benefits as Plan G sold by another company. Three states have their own standard plans.
Medicare physical therapy services are generally covered by Medicare Part B. The cost sharing for most Part B services is 80/20. That is, usually Medicare pays 80% and you pay a 20% coinsurance. Most Medicare Supplement insurance plans cover all of your Part B coinsurance, although some plans generally pay part of your Part B coinsurance.
Generally speaking, if Medicare covers a service, your Medicare Supplement insurance plan must also cover at least part of it. For most medical services, if Medicare denies the claim, your Medigap plan will also deny it. Most providers automatically bill your Medicare Supplement insurance plan once Medicare pays its share.
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What Is Physical Therapy
Physical therapy is a service that optimizes quality of life by utilizing prescribed physical exercise, hands-on care and patient education. Physical therapists may work in hospitals, hospice centers, rehabilitation facilities, doctors offices, fitness centers and private physical therapy practices.
Physical therapy is used to treat patients following injuries, surgeries, neurological episodes such as strokes and patients who are experiencing chronic pain, discomfort and arthritis. Not all physical therapists are the same. Many tend to specialize in one or more specific areas and types of physical therapy.
Physical therapy treatment can involve stretching, exercising, the use of equipment like walkers and more.
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Are There Any Situations When Medicare Wont Cover Physical Therapy
Medicare has strict rules about who can provide PT and how much they can charge for it. The American Physical Therapy Association and related professional organizations warn Medicare patients to beware of myths about limits in skilled nursing and home health and advocate for the Medicare-covered therapy they need.
If Medicare is unlikely to pay for physical therapy, a provider such as a physical therapist, doctor, or home health agency must give you a written statement called an Advance Beneficiary Notice of Noncoverage that explains why coverage isnt expected, along with an estimate of costs. This is to alert you that you may have to pay the costs out of pocket if you choose to have therapy.
Is There A Limit On Medicare Coverage For Outpatient Therapy
Technically, no. There is no limit on what Medicare will pay for outpatient therapy, but after your total costs reach a certain amount, your provider must confirm that your therapy is medically necessary in order for Medicare to cover it.1
In 2022, your provider must confirm your therapy is medically necessary once your total costs reach $2,150 for physical therapy and speech-language pathology , or $2,150 for occupational therapy care. Original Medicare will continue to pay for up to 80 percent of the Medicare-approved amount once your care is confirmed as medically necessary. Your costs with a Medicare Advantage plan may be different, so ask your provider before seeking care.
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Does Medicare Pay For Physical Therapy
Medicare covers physical therapy when medically necessary. When physical therapy happens during or after hospitalization, Part A covers it. Part B pays for outpatient or at-home physical therapy.
You may be responsible for part of the cost. Youll obtain therapy in a hospital, skilled nursing facility, outpatient physical therapy center, or your home.
Part A provides coverage for inpatient physical therapy. If youre in the hospital for at least three days, Part A also pays for therapy in a skilled nursing facility after discharge.
If your doctor prescribes physical therapy, and you havent stayed at the hospital, Part B will cover your therapy. Yet, deductibles and coinsurance will apply. So, be ready to pay a portion of the bills.
How Does Medicare Work For Mental Health Medications
Medicare Part A and Part B do not cover prescription drugs for mental health. You will need to explore other options for prescription drug coverage.
The two plans for prescription drugs include:
Medicare Part D: This provides coverage for prescription drugs at a pharmacy. Your Medicare drug plan should specify which drugs are covered and the costs. This is known as a formulary. Before purchasing Medicare Part D, make sure the drugs you need are on the list.
Medicare Advantage: This is a plan from a private insurer. It combines Medicare Part A, Part B, and Part D. These plans usually have limited networks for healthcare providers.
Medicare plans cover drugs like:
You can buy both Medicare Part D and Medicare Advantage plans. But there is an exception if the Medicare Advantage plan is part of a health maintenance organization or preferred provider organization .
Some of the factors to consider for selecting a Medicare Advantage plan include:
The premiums, copays, and coinsurance, which can vary
The healthcare providers in the network
The coverage for services and medications
You can shop for Medicare Part D and Advantage plans at Medicare.gov. Youâll be able to compare plans, costs, and benefits to help you determine the best plan for your needs.
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Community Mental Health Centers
In addition to services offered at PHPs, community mental health centers offer an alternative to hospitalization. These facilities provide:
- 24-hour emergency care with follow-up
- Day treatment, partial hospitalization, or rehab in line with the patients needs
- Screening for admission to a state mental health facility
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 screening 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 dont show improvement after the first six months , Medicare may stop your therapy.
Original Medicare covers behavioral counseling at 100% of the Medicare-approved amount. Medicare Advantage plans cover the same when you see an in-network provider.
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Medicare Inpatient Mental Health Services
If you do need inpatient care as part of your treatment, Medicare Part A covers services during an inpatient hospital or psychiatric hospital stay. Theres a limit to Medicare coverage if you stay at a psychiatric hospital thats dedicated to treating mental health patients, as opposed to a general hospital. Medicare Part A pays for up to 190 days of psychiatric hospital care in your lifetime.
Even during inpatient stays, Medicare Part B still covers certain mental health benefits, such as physician services.
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