Physical therapy (PT) is rehabilitative care designed to improve mobility, strength, and overall function following an injury, illness, or surgery. Many individuals who could benefit from these services face challenges leaving their homes due to their physical condition. While Medicare covers physical therapy, receiving that care in a private residence is possible only under the rules of the Medicare Home Health Benefit. This mechanism allows beneficiaries to access skilled care, provided they meet strict medical and administrative requirements established by the program.
Qualifying for the Medicare Home Health Benefit
Medicare covers in-home physical therapy primarily when it is delivered as part of the comprehensive Home Health Benefit. To initiate this benefit, a patient must be under the care of a physician, who must certify that the necessary services are medically necessary. The physician also creates a formal Plan of Care that outlines the specific services needed, their frequency, and the intended goals of the treatment.
The services must be classified as “skilled care,” meaning they require the specialized judgment, knowledge, and abilities of a licensed physical therapist or physical therapist assistant. Simple activities that a non-medical caregiver or the patient themselves could safely perform are not covered under this provision. The care must be administered by a home health agency that is approved by Medicare.
The funding for this benefit is drawn from both Medicare Part A and Part B. The required services must be delivered on a part-time or intermittent basis, meaning they cannot require 24-hour-a-day care. For instance, skilled nursing care and home health aide services are limited to less than eight hours per day. Physical therapy services are covered if they are reasonable and necessary for treating an illness or injury. A key administrative requirement is that the patient must be confined to the home, ensuring the care is provided only when the patient’s condition makes leaving difficult.
Defining Homebound Status
The requirement that a patient be “homebound” is a strict standard that determines eligibility for the entire Home Health Benefit. An individual is considered homebound if they meet two distinct criteria due to illness or injury.
The first criterion is that leaving the home must require significant effort, such as needing the aid of supportive devices like crutches or walkers, special transportation, or the assistance of another person to exit the residence. Alternatively, a patient meets this initial criterion if their medical condition makes leaving the home medically inadvisable.
The patient must also satisfy the second criterion: there must be a normal inability for the patient to leave their home. Consequently, any attempt to leave must be considered a considerable and taxing effort.
Absences from the home are permitted without voiding the homebound status, but they must be infrequent and for short durations. Absences for the purpose of receiving medical treatment, such as going to a physician’s office, kidney dialysis center, or an adult day care program, do not count against the homebound rule. Attending religious services is also considered an acceptable absence of infrequent and short duration.
However, a patient would generally not be considered homebound if they leave the residence frequently for non-medical reasons. Regular outings for social activities, shopping, or business purposes will typically disqualify a patient from receiving the Home Health Benefit. The medical record must consistently support the patient’s inability to leave home without considerable difficulty.
Patient Costs and Service Limitations
A significant financial benefit of the Medicare Home Health program is that it covers 100% of the cost for approved in-home physical therapy services. Beneficiaries do not pay a deductible or coinsurance for the skilled services themselves when they qualify for the Home Health Benefit. This complete coverage applies to all medically necessary skilled services, including the physical therapy sessions, as long as the eligibility requirements are met.
If the care plan includes durable medical equipment (DME), such as a walker or wheelchair, the patient is responsible for different cost-sharing amounts under Medicare Part B. After meeting the annual Part B deductible, the patient typically pays 20% of the Medicare-approved amount for the DME. The home health agency should clarify any potential out-of-pocket costs related to equipment before the services begin.
Regarding the scope of services, a common misconception is that Medicare only covers therapy aimed at patient improvement or restoration of function. However, the Jimmo v. Sebelius settlement clarified that Medicare covers skilled care necessary to maintain a patient’s current condition or to prevent or slow decline. This means that if a patient with a chronic condition requires the skilled judgment of a therapist to safely perform a maintenance program, the services are covered.
Coverage hinges on the need for skilled intervention, not the potential for recovery. Therefore, skilled maintenance therapy is covered as long as the services are medically necessary and require the specialized abilities of a qualified physical therapist to be delivered safely and effectively. This provision ensures that patients with long-term or progressive conditions can still access the in-home therapy needed to preserve their functional status.