Medicare limits on physical therapy

[pugmom]

DH has had PT after surgery... probably about 10 or 12 sessions. His surgeon gave him an Rx for more, and the PT facility mentioned that Medicare has a limit on how much they will pay for. They also said they would make sure it would be covered.

He has a UHC supplement besides Medicare. But should we be worried that we will get a bill because he exceeded some limit? How can he check this?

Thanks,
pugmom

 

[REWahoo]

From the "Is It Covered?" Medicare site:

There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.

 

[CRLLS]

The PT can contact the DR or Medicare, I don't know which, to get further treatments approved. This happened about 2 years ago with me. I had thrown out my back and went for 4 weeks of PT. PT went on for about 3 months and Medicare/Medigap covered it all. I am again in that situation. I had arthroscopic knee surgery last Tuesday and got 4 weeks of PT prescribed. I expect it will be more than that as long as progress is being made.

 

[Bamaman]

When my wife had her knee replacement, she went to PT class in the hospital twice a day for 3 days. There were 10-12 in the class, and Medicare was being charged $550 per session twice a day--each. Tell me that the hospital wasn't making some serious money. And the PT was sitting in a chair and moving her feet in little circles--nothing worthwhile. The total knee replacement bill was $92K.

Then she went to rehab for 5 days to learn how to hop on one leg with a walker. The rehab bill was about as much as her basic hospital bill for the knee replacement was.

Medicare starves primary care physicians, but they'll pay fortunes to hospitals, surgeons and especially nephrologists for services like dialysis.

 

[pugmom]

Thanks to all for replying. It is unlikely that these sessions will extend for more than another 10 or so. We will see what the PT place says as far as checking on coverage. After all, they have an interest in the answer as well!

 

[CRLLS]

Thanks to all for replying. It is unlikely that these sessions will extend for more than another 10 or so. We will see what the PT place says as far as checking on coverage. After all, they have an interest in the answer as well!

As I mentioned, the Physical Therapist twice extended my sessions. At the end of each prescription there was an evaluation done. He said as long as I haven't met some minimum level of mobility/strength, and continued to be making progress, Medicare usually would extend the session. That is the way it worked for me. I hope it works for you. YMMV.

 

[wmc1000]

When my wife had her knee replacement, she went to PT class in the hospital twice a day for 3 days. There were 10-12 in the class, and Medicare was being charged $550 per session twice a day--each. Tell me that the hospital wasn't making some serious money. And the PT was sitting in a chair and moving her feet in little circles--nothing worthwhile. The total knee replacement bill was $92K.

Then she went to rehab for 5 days to learn how to hop on one leg with a walker. The rehab bill was about as much as her basic hospital bill for the knee replacement was.

Medicare starves primary care physicians, but they'll pay fortunes to hospitals, surgeons and especially nephrologists for services like dialysis.

What they charge Medicare always seems excessive to us. When we get the EOB however, it seems the actual amounts the various medical professionals and facilities get paid is just pennies on the dollar.

I had PT for a shoulder issue and while Medicare got "charged" over $200 per session, they only paid about $40 per session and the rest was written off by the facility.

 

[Chuckanut]

PT is a lot cheaper than surgery, treatments, etc. etc. etc.

Sometimes I wish Medicare would NOT cover PT so well. That would give me a good excuse to slack off and skip some sessions. But it does, and I don't.

 

[pacergal]

I recently had neck PT, was pre approved by medicare for 7 visits, DH recently went for back PT, pre approved for 10-12 visits.
Both places said no problem if more was needed. Luckily, non were. Co Pay Cost $40 each visit, much less expensive than when I was on work insurance.

 

[Chuckanut]

I recently had neck PT, was pre approved by medicare for 7 visits, DH recently went for back PT, pre approved for 10-12 visits.
Both places said no problem if more was needed. Luckily, non were. Co Pay Cost $40 each visit, much less expensive than when I was on work insurance.

Regular Medicare or Medicare Advantage plan? That's important.

I have regular Medicare with gap insurance. So far my PT from my knee surgery and my back have cost me Zero, nothing, niente, nada dollars.

Friends with Advantage plans have the [-]disadvantage[/-] pleasure of having to pay a co-pay and getting authorized for additional visits.

 

[RetMD21]

Thanks to all for replying. It is unlikely that these sessions will extend for more than another 10 or so. We will see what the PT place says as far as checking on coverage. After all, they have an interest in the answer as well!

MIL had some limits imposed by her Medicare Disadvantage Plan. A lot of times doctors/nurse/therapists are a little unclear on which Medicare is which. I don't think they will have an issue with traditional

 

[Gotadimple]

Regular Medicare or Medicare Advantage plan? That's important.

I have regular Medicare with gap insurance. So far my PT from my knee surgery and my back have cost me Zero, nothing, niente, nada dollars.

Friends with Advantage plans have the [-]disadvantage[/-] pleasure of having to pay a co-pay and getting authorized for additional visits.

Co-Pay vs. Medigap - that's an ongoing discussion here that can't be resolved. Because most MedAdvantage Plans premiums are far less than Medigap. It is a personal financial decision.

Physical Therapy has unlimited visits now (15 years ago the benefit for Medicare was 6 visits a year). Medicare + Medigap may not be a problem in terms of seamless uninterrupted care no added cost care. But. MA plans have a contract with CMC that lets them require prior authorization from the plan before approving more visits.

It is theoretically the way they keep costs down. The patient completes a one page survey every few weeks and that is submitted to the plan (or a third party firm they hire to monitor the benefit), who then approves more visits.

The PTs have ways to work with the plan/third party to get more services approved, as does the patient. It's what one does when they make a financial decision about which type of Medicare coverage to buy (Gap or MA).

- Rita

 

[MissMolly]

We have an Advantage plan and have had zero problems getting approval for additional PT following surgery. Yes, we have co-pay. Our co-pay is 4% of the allowed amount. Assuming the allowed amount is $50, our co-pay is a whopping two bucks.

 

[Chuckanut]

I have no issues with Advantage plans. Each of us picks what is best for our situation.

I do think that when we talk Medicare benefits and costs it's important to mention if one is on traditional Medicare or an Advantage Plan. There are enough differences between them to be significant.

 

[youbet]

I do think that when we talk Medicare benefits and costs it's important to mention if one is on traditional Medicare or an Advantage Plan. There are enough differences between them to be significant.

Agreed and actually you need to go a step further.

For Medicare:

1. Which Part D plan do you have?

2. Which supplement do you have?

For Medicare Advantage:

1. Which Medicare Advantage plan do you have?


We have a lot of fun comparing plans at our house because DW has an Advantage plan (UHC Group PPO) and I have traditional Medicare with a BCBS type F supplement and Cigna Part D plan.

It's always a hoot when folks display their ignorance by assuming all traditional and Advantage plans are the same, as though there are only two possibilities (one of each) available for comparison. But, sigh, that's the world today.

 

[CRLLS]

Let's not forget traditional Medicare with a "Select" Medigap policy. A "Select" policy is the same as the standard Medigap policies except they use a small network of Dr/facilities. I don't know too much more than that. They are cheaper than the standard Medigap policies as one might expect.

 

[Callitaday2022]

Medicare has a dollar cap for PT, OT, and Speech. Don't remember exactly what is grouped together or separate. PT cap is about $2150 a year starting 01 January. What is billed doesn't matter, the money towards the cap is what MC pays. I think we get reimbursed about $100 per vist. So you get around 20 visits per year. If something significant happens (you get your 2nd knee replaced in same year) we apply for a KX modifier. KX modifier adds around $850 more so about 8 more visits. After around 30 total visits you're done, and should be independent on home program.

 

[youbet]

Let's not forget traditional Medicare with a "Select" Medigap policy. A "Select" policy is the same as the standard Medigap policies except they use a small network of Dr/facilities. I don't know too much more than that. They are cheaper than the standard Medigap policies as one might expect.

I have a "Select" Part B supplement. BCBS F Select. They do not limit anything other than hospitals. Dr's, labs, etc., are the same as the non-Select plan.

It was a no-brainer for me. The hospital I generally use is on the list as well as several other local community hospitals. And the major Chicago area teaching hospitals such as Rush, Northwestern, Univ of Chicago, etc., are all there. The network only applies to elective procedures. Emergencies are covered anywhere.

You can change from the Select version to the non-Select version on short notice. If I recall correctly, the first of the next month if you call them by a certain date in the previous month. A couple of weeks or so.

If you do screw up and use a non-network hospital, the only penalty is that you pay the Medicare deductible that they would normally pay.

The savings is not huge, a few bux a month. But the downside seems minimal.

There is no difference in PT coverage, at least with my BCBS F Select plan.

 

[Chuckanut]

It's always a hoot when folks display their ignorance by assuming all traditional and Advantage plans are the same, as though there are only two possibilities (one of each) available for comparison. But, sigh, that's the world today.

A bit off topic, but people do that for many, many things and they do it often. Just look at the when to take SS discusssions. People pontificate on why this age is a no-brainer for everybody, as though we all have the same situation in life. And don't get me started on things like EVs, I-Bonds, and bond mutual funds!!

I would rather have a lot of variety of choices, than be stuck with what works for 51% of the population, or worse a small and loud minority.

Back on topic, I have Blue Cross Premera for my Medigap, and UHC /Optum Walgreens for my part D. They seem to work well for me.

 

[CRLLS]

Thanks for your input Youbet. As I understand it, Select only applies to the Medigap part of payment. You can go anywhere that takes Medicare assignment for service and Original Medicare will cover it regardless of in network or not. It is only the 20% copay that would be not covered by the Medigap supplement plan if out of network, Emergencies excepted of course. Do the Select policies also cover foreign travel emergencies like the full service Medigap plans?

 

[youbet]

Thanks for your input Youbet. As I understand it, Select only applies to the Medigap part of payment.

Yes.

You can go anywhere that takes Medicare assignment for service and Original Medicare will cover it regardless of in network or not. It is only the 20% copay that would be not covered by the Medigap supplement plan if out of network,

With my BCBS F Select plan, it is only the Part A deductible that’s not covered. They would still pay the 20% co-pay.

Do the Select policies also cover foreign travel emergencies like the full service Medigap plans?

Mine does.

 

[RetMD21]

I have no issues with Advantage plans. Each of us picks what is best for our situation.

I do think that when we talk Medicare benefits and costs it's important to mention if one is on traditional Medicare or an Advantage Plan. There are enough differences between them to be significant.

Some just go with the initial lowest cost without understanding the options. OTOH, people have different needs and preferences and either decision can be appropriate.

 

[Z3Dreamer]

Is it time for a another separate thread where we debate the pros and cons of MA vs Medigap? Of course, this would be done with respect.

 

[CRLLS]

Yes. With my BCBS F Select plan, it is only the Part A deductible that’s not covered. They would still pay the 20% co-pay. Mine does.

If I understand it right, you saying that even when you are out of network, the select plan covers the Medicare Part B copay? WOW!