Does Medicare Cover Exercise Programs?

Medicare, the federal health insurance program for individuals aged 65 or older and certain younger people with disabilities, often receives inquiries about exercise program coverage. Understanding how Medicare addresses these programs is important, as coverage depends on the program type and medical necessity. This article clarifies Medicare’s coverage for various exercise-related services.

Covered Exercise Programs and Conditions

Original Medicare Part B covers several exercise-related programs when medically necessary and prescribed by a doctor. These programs help individuals manage chronic conditions or recover from specific health events.

Cardiac rehabilitation programs

Cardiac rehabilitation programs are covered by Medicare Part B for individuals with certain heart conditions. These include a heart attack within the last 12 months, coronary artery bypass surgery, stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or stenting, or a heart or heart-lung transplant. Programs involve physician-prescribed exercise, cardiac risk factor modification, education, counseling, and psychosocial assessment. Medicare generally covers up to 36 sessions over 12 to 18 weeks, with potential for additional sessions if medically necessary.

Pulmonary rehabilitation programs

Pulmonary rehabilitation programs are covered by Medicare Part B for individuals with moderate to very severe chronic obstructive pulmonary disease (COPD). Coverage also extends to those with confirmed or suspected COVID-19 who experience persistent respiratory dysfunction for at least four weeks. These programs combine physician-prescribed exercise with education, breathing retraining, and psychosocial assessment. Medicare typically covers up to 36 sessions over 36 weeks, with potential for more if medically justified.

The Medicare Diabetes Prevention Program (MDPP)

The Medicare Diabetes Prevention Program (MDPP) is covered under Part B to prevent Type 2 diabetes. To qualify, beneficiaries need Medicare Part B coverage, a Body Mass Index (BMI) of 25 or higher (23 or higher if self-identified as Asian), and blood test results indicating prediabetes within 12 months before starting. Participants must have no prior diagnosis of Type 1 or Type 2 diabetes (gestational diabetes is an exception) and not have previously received MDPP services. The program involves core sessions focusing on lifestyle changes, including diet and physical activity, to achieve weight loss.

Medical Nutrition Therapy (MNT)

Medical Nutrition Therapy (MNT) is covered by Medicare Part B for specific conditions like diabetes or kidney disease, or within 36 months after a kidney transplant. A doctor must refer the beneficiary for these services, provided by a registered dietitian or other qualified nutrition professional. MNT services include an initial nutrition and lifestyle assessment, personalized diet plans, and follow-up visits, which may incorporate physical activity recommendations. Medicare typically covers three hours of MNT in the first year and two hours in subsequent years, with no cost-sharing for qualified individuals.

Physical therapy (PT) services

Physical therapy (PT) services, which frequently involve therapeutic exercises, are covered by Medicare Part B when medically necessary. This coverage helps restore function, reduce pain, or prevent decline after an injury, illness, or surgery. There is no annual limit on how much Medicare pays for medically necessary outpatient physical therapy services. However, once costs exceed a certain threshold, the physical therapist must document that services remain medically necessary for continued coverage. These services can be provided in various settings, including a doctor’s office, outpatient rehabilitation facility, or at home under specific conditions.

Accessing Covered Programs

Accessing Medicare-covered exercise programs requires specific steps. The most important step is obtaining a physician’s referral or prescription, as coverage is always contingent on medical necessity.

After receiving a doctor’s order, it is necessary to locate a Medicare-approved facility or provider. You can use the official Medicare website’s provider search tool or call 1-800-MEDICARE for assistance. Confirm with the provider that they accept Medicare assignment.

For most services covered under Original Medicare Part B, beneficiaries are responsible for cost-sharing. This typically includes meeting the annual Part B deductible. After the deductible, Medicare generally pays 80% of the approved amount, leaving you responsible for the remaining 20% coinsurance. In some cases, such as services received in an outpatient hospital department, a copayment may also apply.

Some programs, like cardiac and pulmonary rehabilitation, may have specific session limits. However, additional sessions can be approved if continued medical necessity is documented by your provider. Providers must also confirm that services remain medically necessary once a certain cost threshold is reached for ongoing physical therapy.

Medicare Advantage Plan Coverage

Medicare Advantage Plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare and provide an alternative to Original Medicare. These plans are required to cover all benefits that Original Medicare (Parts A and B) covers, including medically necessary exercise programs like cardiac rehabilitation, pulmonary rehabilitation, and physical therapy.

Beyond standard Original Medicare benefits, many Medicare Advantage plans offer additional health and wellness benefits not typically covered by Original Medicare. These supplemental benefits often include fitness programs and gym memberships. Common examples are SilverSneakers and Renew Active, which provide access to a network of fitness centers, classes, and at-home workout resources.

These fitness benefits are generally offered by Medicare Advantage plans to encourage members to stay active and healthy, often at no additional cost beyond their plan premium. However, specific fitness benefits vary widely by plan and geographic location. It is important to review your Medicare Advantage plan’s Summary of Benefits or contact your plan provider directly to understand which fitness programs are included.