For people 65 and older, navigating and understanding Medicare benefits is very important. First, I’d like to explain basic Medicare terminology and then give some specific physical therapy guidelines.
Medicare is divided into two parts: Part A (hospital insurance) covers a large portion of hospitalization, skilled nursing facility (SNF), home health care and hospice care. There are specific time limits and out-of-pocket expenses for each of these. Most people do not have to pay for Part A.
Part B is considered medical insurance and helps pay for doctors’ services, outpatient hospital care, including physical and occupational therapy, and some home health care. Enrolling in Part B is your choice and a monthly premium is usually taken out of your monthly social security, railroad retirement, or civil service retirement payment.
Health care providers who deliver services to Medicare patients have a choice to enter into an agreement with Medicare to ”accept assignment.” This means that the health care provider agrees to accept a reduced rate set forth by Medicare. Your portion of a bill would therefore also be reduced when using a provider that accepts assignment.
There are two main options for Medicare coverage. The first is the Original Medicare Plan, and the second is a Medicare Managed Care Plan.
The original Medicare plan is a “fee for service” plan. If you have this plan, you use a red, white and blue Medicare card. This plan allows you to go to any doctor, specialist, or hospital in the country that accepts Medicare. Usually, a fee is charged every time you receive medical care. After you pay a yearly deductible, Medicare pays its share of a medical bill and you pay your share.
To help pay medical expenses that the original Medicare Plan doesn’t cover, you can purchase Medicare Supplement Insurance. This supplement insurance can usually be used anywhere in the country and typically covers the remaining portion of a Medicare approved service.
Your second option is to join a Medicare Managed Care Plan. These are sometimes called HMO plans and are offered by private insurance companies. The advantages of this plan often include prescription drugs and minimal out of pocket expenses. The disadvantages include being limited to certain hospitals and geographic areas for doctors. Also, a referral from your primary care physician (PCP) is often required to see a specialist or receive rehabilitation services. If you travel during the winter months, many HMO plans won’t cover you away from your geographic area.
In terms of outpatient physical therapy benefits, Medicare has very specific rules for both patient and provider.
First, a medical doctor, using a written referral or prescription, must request physical therapy. This prescription is only valid for 30 days from the day it is written. For example, if your doctor wrote a prescription for you to receive physical therapy on 12-1-01, it will only cover services through 12-30-01. At the end of that period, if the therapist finds on re-evaluation that further services are needed, another referral from the doctor is required.
The therapist must be able to show both subjective and objective improvements are being made to substantiate medical necessity. Increased range of motion, which is measurable, is an example of an objective improvement. An example of a subjective improvement would be word from the patient that it is easier to walk than before treatment. Medicare doesn’t cover modalities such as hot packs. Also, a condition or diagnosis that is deemed chronic must show improvement. Services that are considered maintenance aren’t covered.
If you have any specific Medicare questions, you can call 1-800-MEDICARE (1-800-633-4227) or find information on the web at Medicare.gov.