Does Medicare cover physical therapy at home?

After a fall, a fracture, a stroke, a hospital stay or simply a slow decline in strength, physical therapy is often the difference between staying home and not. For an older adult who cannot easily get to a clinic, the question is whether the therapist can come to them. The answer is yes, in two different ways, and knowing which applies saves both money and weeks of confusion.

If your parent is homebound, meaning leaving home takes a considerable and taxing effort and requires help or a device, or is medically inadvisable, and a doctor certifies the need for skilled therapy, a Medicare-certified home health agency provides physical, occupational and speech therapy at home with no deductible and no coinsurance. Nursing, a home health aide and medical social work can be included. A face-to-face visit with the certifying practitioner within 90 days before or 30 days after the start is required; a hospital stay or a recent doctor’s visit usually satisfies it.

• Any doctor, nurse practitioner or physician assistant can order it; it does not have to follow a hospital stay.
• Care is certified in 60-day periods, renewable while she still qualifies.
• Frequency is set by the plan of care, typically two or three visits a week per discipline, each 45 to 60 minutes.
• The agency must give written notice before Medicare-covered care ends, and you can request a fast appeal.

If your parent is not homebound but getting to a clinic is difficult, some outpatient therapy practices send therapists to the home and bill Medicare Part B exactly as if the visit happened in the clinic. This is sometimes called mobile outpatient therapy or “Part B in the home”. It requires a doctor’s referral and a plan of care, and the patient owes the Part B deductible and 20 percent coinsurance per visit, usually covered by Medigap or Medicaid.

• Useful for people who do not meet the homebound definition, or who have finished home health and need to continue.
• Availability varies by area. Ask the doctor’s office, or search for “mobile outpatient physical therapy” plus your city.
• The therapist must be Medicare-enrolled and the practice must accept assignment to limit your cost to the coinsurance.

Medicare covers therapy as long as it requires the skills of a therapist and is reasonable and necessary, whether the goal is improvement or maintaining function and preventing decline. The Jimmo settlement made clear that a “plateau” is not grounds for ending coverage when skilled therapy is still needed to maintain function. Therapy does end when the patient can safely continue a home exercise program independently or with family help, and a good therapist will say so and leave a written program behind.

1. 1.Ask the therapist why. If the reason is a visit limit or “Medicare won’t pay”, ask them to show you the rule. It usually does not exist.
2. 2.If home health is ending, request the written Notice of Medicare Non-Coverage and file a fast appeal through the Quality Improvement Organization if she still needs skilled therapy.
3. 3.If home health has legitimately ended because she is no longer homebound, transition to outpatient therapy, at home or in a clinic, with a new referral.
4. 4.If the issue is the specific agency or therapist, ask the doctor for a referral elsewhere. You have a choice of providers.
5. 5.Ask about a maintenance program. Even after discharge from active therapy, periodic therapist visits to adjust a maintenance program can be covered.

• Be there for the evaluation and ask what the goals are and how long the therapist expects to be involved.
• Ask for the home exercise program in writing, with pictures, and help her do it on the days the therapist does not come. Therapy twice a week does little without practice on the other five.
• Ask the therapist to look at the house: the bathroom, the stairs, the bed height. Occupational therapists in particular will recommend equipment and changes, and their written recommendations help with Medicare equipment orders and other funding.
• Report falls, pain and changes to the therapist promptly. They adjust the program, and they communicate with the doctor.