Medicare covers physical therapy (PT) provided in the home, but this coverage is managed through the Medicare Home Health Benefit and is subject to strict qualifying criteria. This benefit is designed for individuals who require skilled medical services following an illness or injury and who face difficulty leaving their residence. Understanding the specific rules regarding eligibility and costs is necessary for beneficiaries to access this service. Coverage details change depending on whether a person has Original Medicare or a Medicare Advantage plan.
How Original Medicare Covers Home Physical Therapy
Original Medicare covers in-home physical therapy when it is medically necessary and furnished by a Medicare-certified home health agency. This coverage falls under the Home Health Benefit, funded by both Medicare Part A and Part B. The primary purpose of this therapy is to help a person recover, regain function, or manage a condition after a decline in health. The therapy must require the skills of a licensed therapist, such as gait training, therapeutic exercise, or manual therapy techniques. Medicare pays the home health agency a bundled rate for all services provided during a specific period of care.
Essential Eligibility Requirements for Home Health Services
To receive Medicare coverage for in-home physical therapy, a person must first be certified by a physician as requiring skilled services and needing to be confined to the home. The physician must create and sign a plan of care before the services begin. The care itself must be provided on an intermittent or part-time basis, meaning it cannot be continuous or round-the-clock care.
The most specific requirement is the “homebound” status, which does not mean being unable to leave the house at all. A person is considered homebound if leaving requires a considerable and taxing effort, often needing the help of a supportive device like a cane or wheelchair, or assistance from another person. Permissible absences include leaving for medical treatments, attending religious services, or very short, infrequent trips for non-medical reasons.
The physical therapy itself must qualify as “skilled care,” meaning the complexity of the service is such that it can only be safely and effectively performed or supervised by a licensed physical therapist. This is distinct from general assistance, which is considered custodial care and is not covered by the benefit if it is the only care needed. The goal of the therapy must be to improve the patient’s condition, establish a maintenance program, or prevent further decline.
Financial Responsibility and Costs
For beneficiaries covered by Original Medicare, the cost structure for covered home health physical therapy is straightforward. If all eligibility criteria are met and the services are medically necessary, the beneficiary pays nothing for the skilled physical therapy visits. Medicare pays 100% of the approved amount for the home health services provided by the agency. Costs may apply if the physician prescribes durable medical equipment (DME), such as a walker or a wheelchair, as part of the recovery plan. DME is covered under Medicare Part B, which requires the beneficiary to pay the Part B deductible and a 20% coinsurance. The home health agency will inform the patient in writing about any potential costs not covered by the Home Health Benefit.
Coverage Differences in Medicare Advantage Plans
Medicare Advantage (MA) plans, also known as Part C, must cover at least the same services as Original Medicare, including the Home Health Benefit. However, the way these services are administered and the associated costs can differ significantly. MA plans implement their own rules for accessing care, often requiring the use of a home health agency within the plan’s specific provider network to receive the maximum benefit.
These plans frequently utilize prior authorization, where the plan must approve the service before it is delivered for coverage to apply. This process ensures the plan agrees that the physical therapy is medically necessary. Unlike the $0 cost for the therapy under Original Medicare, MA plans may impose cost-sharing through copayments or deductibles for home health services. These out-of-pocket costs vary widely, so beneficiaries must review their specific plan documents to understand their financial responsibility.